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

Unemployment Compensation: Unemployment weekly benefit printout.



Self Employed, Farm, and Rental Income: The first 2 pages of your most recent IRS-1040 tax return and

relevant schedules (C, E, F, SE), or you may submit a Tax Transcript which you can download from the IRS

website at https:// If you did not file taxes or you have been self-

employed less than 2 years, call your local EAP Service Provider and ask for a Self-Employment Form or

download the form from eap.IHCDA.in.gov. Enter the date your business started in the space provided on

page two of the application.



Interest, Dividend: Bank statements or your IRS-1099 or IRS-1040.



Retirement Income: Benefit checks/stubs, bank statements or award letter.



Pensions and Annuities: Benefit checks/stubs, bank statements or award letter.



No Income: If your household has no income and no one is self-employed, call your local EAP Service Provider

for a Verification of Zero Income Affidavit and an Indiana Workforce Development Release of Information. You

will also find these form on eap.IHCDA.in.gov. BOTH forms must be filled out for EACH person claiming zero

income.



Deductions: You may deduct any child support payments you made to someone else to support your child.

Please provide proof of payment.



Other Income: Please let us know if you receive any other the other benefits listed in this section. These

benefits will NOT count as income for EAP eligibility. You do not have to send in proof that you receive these

benefits.



Weatherization Assistance Program (WAP) Income Eligibility Guidelines

You may be eligible for the Weatherization Assistance Program (WAP) even if your household’s income is

higher than the EAP limits. WAP provides free home energy upgrades to income-eligible homeowners and

renters to help save energy and make your home a healthy and safe place to live. Please indicate if you are

interested in being referred to the weatherization program. For income eligibility please refer the Indiana

Weatherization Assistance Program at

eap.IHCDA.in.gov

or (800) 872-0371

**Please send a copy of your proof of income. Originals will not be returned**

You will be eligible for EAP if you are under 150% of the Federal Poverty Level.

PART 5. Housing Information: Homeowners: Check the type of housing you live in. You are a homeowner if you own,

are buying your home, have a home mortgage or contract for deed, or have a Life-Estate. You may qualify for additional

benefits if you own your home. If you are a renter please provide a lease or Landlord Affidavit. If you don’t have a

landlord affidavit, you can download one at

eap.IHCDA.in.gov.

If your utilities are included in your rent, you can still qualify

for an EAP benefit and we may pay you directly. You must provide proof that the utilities are in the Landlord’s name by

providing the lease or Landlord Affidavit.

PART 6. What is your primary heat source? Enter the name of the heating and electric company providing energy to your

home. Send a copy of your last heat and electric bill. For Bulk fuel, send a fuel receipt. If the name or one of your

household members name is not the name on the account, call your local service provider. If your bills are in your

landlord’s name, include a lease or a Landlord Affidavit.

PART 7. Consent and Signature:

Read the permissions carefully. An adult household member, 18 years of age and

older or emancipated minor, must sign the application. Any other person signing the application must have be an

Authorized Representative or have a Power of Attorney (POA) to actions behalf of the household and must submit a

copy along with the application. Return the application to your local EAP Service Provider.

Self-Declaration of Primary Fuel Source Level: This section is only for clients who use bio-fuel or a pre-paid utility

service who will have an energy crisis within ten days. By filling out this section you are certifying that you are within

10 days of having no heat due to low fuel source or prepaid utility. All other applicants can skip this section.

Instructions For Indiana Energy Assistance Program Application Form - Indiana Housing And Community Development Authority - 2017-2018 Page 2

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