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West Virginia Income Maintenance Manual Chapter 21

West Virginia Income Maintenance Manual Page 2 Chapter 21 Low Income Energy Assistance Program (LIEAP)

21.2 LIEAP FORMS One or more of the following forms may be used in connection with the application itself (DFA- LIEAP-1) and the processing of the LIEAP payment. • The DFA-LIEAP-1a, Instructions for Completing the Application Form, also provides the current LIEAP income guidelines and directions for mailing the form and obtaining additional assistance. • The DFA-LIEAP-1b, Supplemental LIEAP Form shelf document, is used to document the application process. • The DFA-LIEAP-ERR-1 application for assistance with repair or replacement of a heating unit. • The DFA-LIEAP-3, Repayment Agreement, is used to initiate the repayment process when a LIEAP payment has been issued in error. • The DFA-LIEAP-4, Zero Income/Home Heating/Cooling Cost Verification form, is used when the client reports zero income. • The DFA-67, Authorization for Payment, is used to authorize Regular LIEAP payments on behalf of the client experiencing a heating emergency. • The DFA-LIEAP-5, Authorization for Delivery and Payment of Emergency/ Regular LIEAP, is used as an option to the DFA-67 when desired by the local LIEAP staff and accepted by the vendor. • The DFA-67, Authorization for Payment, is an eligibility system-generated voucher for the authorization and payment of Emergency LIEAP. • The DFA-LIEAP-6, LIEAP Application Log, can be used by the county DOHS office to track LIEAP applications and ensure timely processing and issuance of checks. Use of this form is optional, but the use of some type of log is mandatory. • DFA-LIEAP-8, LIEAP Repayment Tracking Form, is used by the Repayment Investigator (RI) to track LIEAP overpayments. In addition to the forms listed above, the LIEAP Fact Sheet is provided to local offices for distribution to the public.