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DFS Form 1460 Revised 9/01/2012

COMPLETE PAGES 1-7 PLEASE USE BLACK INK

WYOMING LIEAP AND LOW-INCOME WEATHERIZATION APPLICATION FORM IF YOU NEED HELP COMPLETING THIS APPLICATION, CALL THE LIEAP OFFICE AT Phone: 1-800-246-4221 FAX: 307-778-3943 You can get another copy of this application at: http://dfsweb.state.wy.us/

TELL US YOUR ADDRESS 1. APPLICANT: (Print or type your information. The person completing the application is usually considered the head of household and must provide proof of lawful presence and residence.) Last Name

First Name

Middle Name

Maiden or Previous Name

Address of Residence (Utility Service Address)

City

State

Zip Code

Mailing Address or PO Box (If different from Residence/Service)

City

State

Zip Code

Your Email Address

Date of Birth

In which County do you live?

Phone 1: Phone 2:

If you wish to appoint an authorized representative to act on your behalf for the purposes of providing information necessary to determine your eligibility, and to assist with this application, please list the person’s name, address and phone number below. The representative must also sign below and provide a copy of his/her ID. Name

Address

Phone Number

Signature

TELL US WHO LIVES IN THE HOME 2. HOUSEHOLD MEMBERS Complete the information below for all persons living in your home including yourself. Remember to list ALL people even if they are not related to you or are just temporarily living with you. If you need more room, please attach another sheet.

Name (first & last) (List yourself first and then all Relationship household members) to You

U.S. Registered Disabled? Citizen? Alien? * Date of Birth

Race Age Sex

Social Security Number

Yes

No

Yes

No

Yes

SELF

* If you (or members of your household) are a registered alien, please attach a copy (front and back) of the alien registration card(s) to the application.

1

No


Are you a Native American and live within the boundaries of the Wind River Reservation? Yes

No

If Yes, are you Shoshone

Northern Arapaho

Other_____________________________________

Are you or anyone in your household receiving public assistance? Check all types of assistance received. TANF/POWER FOOD STAMPS/SNAP

Yes

No

MEDICAID

OTHER (specify): ___________________________________________________________________________ TELL US ABOUT YOUR HOUSE 3. LIVING ARRANGEMENTS: (Check the item that best describes where you live.) Dormitory House RV (permanently parked) Duplex/Triplex/Fourplex

Van/Car

Fraternity/Sorority House

Townhouse

Rooming/Boarding House

Rehabilitation Center

Apartment/Condo

Hotel

Correctional Facility

Mobile Home

Group Home

Nursing Home/Residential Facility

Other, Specify:________________________________________________________________________ Do you

Own

Rent

If you Rent: Do you live in subsidized, low-income housing (Section 8, senior citizen apartments, public housing, etc.)? You must provide copy of rental agreement, lease or form DFS 109 from Department of Family Services. Do you receive a utility allowance? (Do Not Include LIEAP)

Yes

No If Yes, Monthly Amount ______________

What is your landlord's name? _________________________________Phone__________________ Address___________________________________________________________________________________

4. TELL US ABOUT STUDENTS IN THE HOME List all persons in the home who attend High School, College or Voc. Tech. School. Name of Student

High School

College/Voc. Tech.

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

For full-time college students with no income, provide proof of good standing and class registration. High School students who are working need to provide proof of school attendance.

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TELL US ABOUT HEATING SUPPLIER & RENT INFORMATION 5. HEAT/RENT INFORMATION: Tell us about the home you live in and how it is heated. If your rent includes the cost of heat, you will need to provide the name and address of your landlord and a copy of your rental agreement. If you do not know what type of heat your home uses, check with your utility company or landlord. YOU MUST ATTACH A RECENT HEATING BILL OR FUEL SUPPLIER STATEMENT. PRIMARY HEAT SOURCE: Check the Main fuel used to heat your residence (not the power source). This is the fuel your heat system uses to heat your house, not the power source needed to turn the furnace on. Check only one. This is your primary heat source. Natural Gas Propane Electricity Wood/Pellets Coal Home Heating Oil Other Check the way in which the main heat source (heating fuel, not heating power) is paid for at your residence. 1. I pay heating costs directly to a utility company or fuel dealer. Name of fuel provider: ________________________________ Billing account number: ____________________ 2. Heat is included in my rent. ( Attach a copy of the most recent rental agreement. If not available call I do not pay utility portion to landlord the LIEAP office for Form DFS 109.) I pay utility portion to landlord 3. Someone other than a member of my household pays my heating costs, and I in turn pay them. Provide name and address of that person and his/her relationship to you. ( Attach a copy of most recent heating bill.) Name: ___________________________ Address:_________________________ Relationship:____________ 4. My primary heating bill is in someone else’s name. Explain why your heating bill is in another name: _________________________________________________ _________________________________ SECONDARY HEAT SOURCE: Check the Secondary (if applicable) fuel used to heat your residence (Ex: Primary is gas, but you also have a wood stove. Wood would be your secondary heat source. This is secondary to your main heat source.) What is your secondary heating source? Check only one. Natural Gas Propane Electricity Wood/Pellets Coal Home Heating Oil Other Check the way in which the secondary heat is paid for at your residence. 1. I pay heating costs directly to a utility company or fuel dealer. ( Attach a copy of most recent heating bill.) Billing account number: ____________________ Name of fuel provider: ______________________________ 2. Heat is included in my rent. ( Attach a copy of the most recent rental agreement. If not available call the LIEAP office for Form DFS 109.) I pay utility portion to landlord I do not pay utility portion to landlord 3. Someone other than a member of my household pays my heating costs, and I in turn pay them. Provide name and address of that person and his/her relationship to you. ( Attach a copy of most recent heating bill.) Name: ___________________________ Address:___________________________ Relationship:_____________ 4. My secondary heating bill is in someone else’s name. Explain why your heating bill is in another name: ______________________________________________________________________________________

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TELL US ABOUT INCOME 6. HOUSEHOLD FINANCIAL INFORMATION: REPORT GROSS (amount before deductions) INCOME from *Wages, *Self-employment, *Child Support, *Alimony, *Social Security, *SSI, *BIA GA, *TANF, *Unemployment, *Workers’ Compensation, *Disability Payments,*Veteran’s Benefits, *Retirement, *Pensions, *Annuities, *Dividends, *Rental Income, *Prizes, *Money from Family or Friends, and *all other sources of income FOR ALL PERSONS IN THE HOME WHO RECEIVE INCOME. ATTACH PROOF: Examples of proof are:  Money from work: 3 most recent consecutive pay stubs or Employers Statement form DFS 106  Money from Self-employment: Copy of the most recent income tax return (INCLUDE ALL PAGES AND SCHEDULES OF THE TAX RETURN.)  Money NOT from work: Award letters, Tax forms 1099  Money from Social Security or SSI ONLY: Copy of checks or bank statement showing automatic deposit, or SSA Benefit Letter, or Tax form 1099  If no income: Statement explaining how expenses are being met with no income report or DFS form 1461 If you send your application in: September October November December January February

Send proof of all income received in: June 1 – August 31 July 1 – September 30 August 1 – October 31 September 1 – November 30 October 1 – December 31 November 1 – January 31

If you send your application in: March April May June July August

A. EARNED INCOME FROM WORK - Is anyone in the household working? Household Member Receiving Work Income

Employer’s/Company’s Name

How often paid?

YES

Send proof of all income received in: December 1 – February 28 January 1 – March 31 February 1 – April 30 March 1 – May 31 April 1 – June 30 May 1 – July 31

NO

Total Gross Monthly Income

If unemployed, under age 50, and not pregnant or a single adult household with child under age 6, you must provide proof of registration with Department of Workforce Services at time of application. STOP: ATTACH 3 CONSECUTIVE PAY STUBS FOR ALL HOUSEHOLD MEMBERS Listed Above. If pay stubs are not available call the LIEAP office for a DFS 106 employer statement form.

Is anyone in the household Self-Employed?

YES

NO

B. INCOME FROM SELF-EMPLOYMENT (Include baby-sitting, child care, ranching, house cleaning, etc.) Type of Self-Employment

Address

Household member who receives it?

How often paid?

Gross Monthly Income

ATTACH PROOF OF SELF-EMPLOYMENT INCOME TAX FORMS AND APPROPRIATE SCHEDULE or PROFIT and LOSS STATEMENT

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C. OTHER INCOME SOURCES Please check all that apply to your household. Household member receiving it

Type of Income

How often paid?

Gross Monthly Income

Alimony/Spousal Maintenance Child Support Money from others, such as friends or relatives Pensions, Retirement, or Railroad Retirement POWER/TANF (Temporary Assistance to Needy Families) Social Security Supplemental Security Income (SSI) Unemployment Insurance Compensation Veteran’s Benefits (VA) Workers’ Compensation/Disability/Illness Benefits Other income, explain: (Adoption Stipends, etc.) I do not receive any income. Attach a statement explaining how expenses are being met with no income or submit form DFS 1461 Self Declaration of Zero Income TELL US ABOUT CHILD SUPPORT EXPENSE

Does any person in the home pay child support to another household?

Yes

No

If yes, list who pays it. __________________________ How often, and at what amount? ___________________ Please attach proof of the amount paid for the most recent three (3) months. IF YOU ARE FACING A HOME HEATING EMERGENCY, SUCH AS A SHUTOFF OR PENDING SHUTOFF, OR NON-WORKING FURNACE/BOILER/HEAT SYSTEM, CONTACT THE LIEAP OFFICE NOW: 1-800-246-4221

Mark any of these that apply to you today Less than 10% fuel remaining (propane, wood, pellets, coal, oil) Propane Tank set Need utility deposit (attach letter from utility company with the deposit amount quote)

Disconnect Notice (attach copy of the notice) APPLICANT RESPONSIBILITIES I understand that the LIEAP office may require proof of any information provided in this application or subsequently reported to the LIEAP office. I am aware that failure to provide proof of lawful presence, income and heating costs will result in denial of LIEAP benefits. I hereby authorize release of information concerning my LIEAP application and benefits to my utility company and/or fuel dealer if necessary for a vendor payment, to prevent shutoff, or to obtain energy usage data information for LIEAP or weatherization purposes. My Social Security Number may be used to request and exchange information with other agencies as part of the eligibility verification process. I am aware that I have the right to a fair hearing appeal and to obtain the assistance of legal counsel in the event of a denial, reduction, or termination of my assistance, and in other matters for which such appeal rights exist.

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I declare that the information given by me in this application is true and correct. I understand the penalty for providing false information shall be no more than a $15,000 fine, or not more than 5 years imprisonment, or both. I understand that a person is only allowed to receive LIEAP benefits in one household during the year from one agency. I may not receive State LIEAP and Tribal LIEAP in the same year. I understand that my LIEAP benefit is not intended to pay for all of my heating costs. I am responsible for paying any costs still owed to my heating provider or my landlord (as applicable). I also understand the LIEAP benefit is seasonal and that I must reapply each season, and that any remaining benefit will revert back to the State to be re-distributed to eligible applicants during the next LIEAP season. Remaining benefits are not refunded.

NOTE: Weatherization Assistance Program applications are approved year round. LIEAP applications are approved during the LIEAP program season and will not be accepted following the th application deadline of February 28 . Applications are processed in the order in which they are received. By my signature below, I certify, under penalty of perjury, the truth of the information contained in this application, including the information concerning citizenship and immigration status I provided for all people living in my home. I give my consent for any person, agency, or institution to supply information to the Department of Family Services about myself or my family and to allow inspection and copying of records about myself or my family by any representative of the Department. I also authorize the Department to openly discuss and share all information regarding my case with Authorized Representative should I elect to appoint one.

8. REQUIRED HOUSEHOLD MEMBER/APPLICANT SIGNATURES – UNSIGNED APPLICATIONS WILL NOT BE PROCESSED AND WILL BE RETURNED FOR REQUIRED SIGNATURES. All adults (18 years of age or older) living in the household must sign and date the application. Signature:

Date:

Signature:

Date:

Signature:

Date:

Signature:

Date:

Signature:

Date:

9. COMPLETE, SIGN, AND SEND THE ENTIRE APPLICATION (pages 1 through 7) and SUPPORTING DOCUMENTS TO: LIEAP Application Processing P.O. Box 827 Cheyenne, WY 82003-0827 -orFAX to: 307-778-3943

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WEATHERIZATION INFORMATION If eligible for LIEAP, you may also be eligible for WEATHERIZATION ASSISTANCE, at no cost to you, to help reduce energy costs. A Weatherization Agency may contact you. If you have received weatherization at this residence between September 1994 and today’s date, Stop here. If you have never received weatherization at this address, or if you received weatherization at this address before September 1994, please continue. I HAVE READ AND AGREE WITH THE FOLLOWING STATEMENTS.

1. My home is not projected for sale or rent within the next twelve (12) months. 2. To the best of my knowledge, a Department of Energy related program has not previously provided weatherization assistance to this house. 3. I certify that I am the legal owner or this residence, or that I will provide a rental agreement to the Weatherization Agency signed by the true owner or owner’s authorized agent or manager. 4. I authorize that this dwelling may be weatherized in accordance with the guidelines and procedures established by the Department of Energy and the State of Wyoming. 5. I understand that the dwelling for which this application is made can be weatherized one time. 6. I understand that I will be placed on a waiting list based on a priority point system and that approval does not guarantee that I will receive weatherization services this year. 7. I understand that it is my responsibility to contact the appropriate weatherization agency about any problems or concerns with the work done to my home within twelve (12) months from the date that the work was completed. I further understand that it is best to report problems within thirty (30) to sixty (60) days to ensure a prompt and satisfactory resolution. TELL US ABOUT THE HOUSEHOLD MEMBERS ADDITIONAL INFORMATION Check all that apply to the members of your household. Children aged 0-2 years Handicapped or disabled Name(s):_________________ Children aged 3-5 years

Received LIEAP last year

Received Weatherization Before

Person 60 years or older

Employed

Unemployed HEALTH CONDITIONS

Do you have any known or suspected occupant health concerns that we should be aware of? Yes __no __ IF YES, WHAT ARE THEY? ________________________________________________________ DO THESE CONDITIONS INCLUDE ANY OF THE FOLLOWING HUMAN &/OR HOME CONDITIONS? Check all that apply. _Allergies _Eyesight Problems

_Breathing Problems _ Hearing Problems

_Heating System _Fire Hazards

_Headaches _ Odors

_ Dizzy Spells _Pests

_Mobility Problems

_ Skin Problems

_Electrical Issues

_Mold/Moisture

_Structural

ARE YOU OR ANY HOUSEHOLD MEMBERS CURRENTLY ON OXYGEN? ____YES ____NO If you are a renter in an apartment complex, please answer the following: What is the name of the apartment complex? __________________________ How many units does the apartment complex have? _________________ By signing here, I certify under penalty of perjury, the truth of the information contained in this application, including the information concerning citizenship and immigration status I provided for all people living in my home.

SIGNATURE:________________________

DATE:__________________

NOTE: THIS PAGE IS PART OF THE APPLICATION AND MUST BE COMPLETED AND RETURNED WITH PAGES 1 – 7 IF YOU ARE REQUESTING WEATHERIZATION SERVICE.

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