Application For State Emergency Relief - Dhs-1514 (Page 3 of 4) in pdf

Case Name

Case Number

Specialist

HOUSEHOLD INFORMATION FOR THE PAST SIX MONTHS

Complete the chart below to tell us about your expenses, income and how many people live with you for the last six (6) months. If you did not have the

expense, write “NONE” in the box.

6 MONTHS AGO

1 MONTH AGO

2 MONTHS AGO

3 MONTHS AGO

4 MONTHS AGO

5 MONTHS AGO

Month

# of people in home

Total monthly income

Rent/Mortgage amount

Heat

Electricity

Water, Sewer &

Cooking Gas

Yes  Check all that apply and ATTACH PROOF.

INCOME EXPENSES

Does your household pay any of the following?

Health insurance premium $

Paid how often?

Covers what time period (1mo., 3 mos., etc.)

Court ordered child support (amount paid per month)

Actual child care costs paid by the employed person, not MDHHS

Unusual employment related expenses $

Explain expense

BURIAL - If you are applying for burial services, please complete this section. Be sure to answer income, vehicle and asset questions for the

individual, his or her spouse or parent(s) of a minor child. ATTACH PROOF.

Name of deceased

Date of death

Is this a cremation?

Date of burial/cremation

Yes

Name of funeral home handling services

Address of funeral home

Phone # of funeral home

Is payment to the cemetery or crematory separate from

Place of burial/name of cemetery or crematory

Is there a memorial service?

the payment to the funeral home?

Yes

What is the total cost of the burial/cremation?

Is the deceased a veteran?

Did you sign a statement of Goods and Services

with the funeral home?

Yes

What is your legal relationship with the deceased?

Is there a contribution from family and/or friend?

Did the deceased own his or her home?

Yes  Amount $

Yes

Address of home:

Indicate any death benefits applied for or expected to be received and the amount.

Accident/automobile insurance $

Pre-paid funeral agreement $

Veteran’s death benefit $

Social Security death benefits $

If yes, is there a co-owner?

Yes

Life Insurance $

Community assistance fund/fraternal organizations $

Name of co-owner:

Labor union benefits $

Other benefit (specify source) $

SIGNATURE REQUIREMENT

I understand failure to provide the above information may result in denial of my application. I understand I have eight calendar days to

provide all verifications requested. I understand giving false information can result in referral to the prosecutor for fraud. I understand that my

application may be one of those chosen for a complete investigation. A department representative may call at my home and may contact

other people in order to verify my eligibility for assistance.

I authorize the department to release my name and address to the local weatherization operator as part of the Weatherization Referral

system. I authorize the department to release case and payment information to the Michigan Department of Health and Human Services, its

affiliates and/or contracted agencies, for the purpose of research, study and evaluation of the Low Income Home Energy Assistance

Program (LIHEAP).

I authorize my energy company to release by phone, fax, email or their computer web site all available information about my account.

UNDER PENALTIES OF PERJURY, I SWEAR OR AFFIRM THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO ME. IF

I AM A THIRD PARTY APPLYING ON BEHALF OF ANOTHER PERSON, I SWEAR THAT THIS APPLICATION HAS BEEN EXAMINED

BY OR READ TO THE APPLICANT, UNLESS THE APPLICATION IS FOR A DECEASED PERSON. TO THE BEST OF MY

KNOWLEDGE, THE FACTS ARE TRUE AND COMPLETE.

Signature of applicant or authorized representative Date

Signature of spouse

Date

Current address

Signature of MDHHS specialist

Date

Current phone number

Identification of applicant or authorized representative

DHS-1514 (Rev. 11-15) Previous edition obsolete.

Application For State Emergency Relief - Dhs-1514 Page 3

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