Application Form For The Low Income Home Energy Assistance Program
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4APPLICATION FOR THE LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP)
To apply for Energy Assistance, you must complete all questions front and back and sign at the red “X”. Be sure your correct and complete name and address is
YOU CAN ALSO APPLY ONLINE AT
entered below. If incorrect, cross out and PRINT correctly in space provided below.
Philadelphia CAO
Low Income Home Energy Assistance Program (LIHEAP)
1348 W. Sedgley Ave.
Philadelphia, PA 19132-2498
Your County Assistance Office Address
YOUR NAME AND ADDRESS
DPW USE ONLY
CRISIS
CASH
If you do not understand these instructions, contact your local county assistance office.
Application Registration Number
Please complete this section for the head of household.
1
County
*Use the codes from page 2 to help provide the details.
District
Name (Include Last, First Middle Initial)
Date of Birth
Sex
Social Security Number
Record Number
Home Address (Include Street, Apt. Number, City, State & Zip Code+4)
Worker I.D.
Mailing Address if different (Include Street, Apt. Number, City, State & Zip Code+4)
County You Live In
Phone Number:
Citizenship*
Race (Optional)*
Ethnicity (Optional)*
Marital Status*
Are you currently receiving Cash, Medical Assistance or
If yes, may we use the income you have on file for this
Yes
Yes
¨
¨
SNAP/Food Stamp Benefits?
application?
Rejected
Approved
No
No
Date
2
Do you read, write and understand English?
Yes
No If no, what language?
________________
3
¨
¨
Does anyone in your household receive financial assistance for a disability?
Yes
No
4
Show the name, address and account number of the utility company or fuel dealer to whom you want payment sent.
Account Number
Name of Utility Company or Fuel Dealer
Philadelphia Gas Works
Address (Include Street, City, State & Zip Code+4)
800 W. Montgomery Avenue, Philadelphia, PA 19122
5
Are You:
Renting with heat included
Renting subsidized housing/Section 8 housing with heat included
Renting with heat not included
Renting subsidized housing/Section 8 housing with heat not included
An unrelated roomer
An owner or are you buying your home
Other:
_______________________
¨
¨
5a
If you are in subsidized/public housing, do you receive a utility allowance check?
Yes
No
If yes, how much? $ ________
(If heat is included in your rent, attach a note from your landlord stating that heat is included as well as what type of fuel is used.)
Pennsylvania’s Fast And Easy Way To Apply For Your
LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM
PWEA 1 7/13
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