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Low Income Home Energy Assistance Program Division 10 Service 415 Program 415 Chapters 05 - 65 North Dakota Department of Health and Human Services

List Net Income Of Each Household Member For The Month Of Emergency Application Household should list income information for all household members for the current month, including who received the income and its source and employer. This should be net, "take home' pay.

List Assets of Each Household Member Request information regarding checking, savings and other account balances.

Expenditures For The Month Of Application Expenses should be only those for the current month and should not include any arrearages so you have an accurate picture of usual, on-going expenses. Payments required on arrearages can be noted as "other mandatory expenses."

If the household receives housing assistance or SNAP, only the amount the applicant pays "out-of-pocket" should be listed.

See Eligibility Guidelines 415-50-10-10 to determine the allowable expenses for one month.

Note: Verifications are only needed if information is questionable.

Signature Have a household member sign and date the application.

"AGENCY USE ONLY"

Local Action: Check whether approved or denied and describe what is to be paid.