LIHEAP Utility Assistance Application


Please read/use this form—it may help answer questions you have.

□  Energy Intake Form(s) CSD 43

Fill out and sign/date form

□  CSBG Intake Form 2017

Fill out and sign/date form

□  Client Education Confirmation of Receipt CSD 321

Name, Age of your home, home address, signature and date.

□  CSD Consent Form CSD 081

By signing this form, you give your consent (permission) to CSD, its contractors, consultants, other federal or state agencies (CSD Partners) and to your utility company and its contractors, to share information about your household’s utility account, energy usage and/or other information needed to provide the services and benefits to you described on the back of this form.

□  *Electric Bill

Bill must contain a billing period of at least 22 days

□  *Propane Bill

Bill must contain a billing period of at least 22 days

* Both bills are required for processing.

□  Disconnection notice

Is required for accounts that have been or are about to be disconnected. You must also provide the statement before disconnection.

□  Utilities Included in Rent Statement

Must include address, account number, usage (KwH) and signature of Landlord.

□  Household Income:


Gross Wages→ Copies of check stubs for each pay period for the last 30 days.

Self-Employment → A detailed statement showing GROSS monthly income, signed.

Jobs Paid in Cash → Complete Form CSD43B (included).

TANF or Cash Aid → County Notice of Action or Passport to Services (current).

Unemployment Stubs → Stubs must cover the last 30 days.

Child Support → Bank Statement showing deposit, or State Form (current).

Social Security → Annual Award Letter or Current Bank Statement with Deposit.

Pension or Annuities → Annual Award Letter Showing Gross Yearly Earnings.

Tribal Per-Cap → Annual, Quarterly or Monthly, Statement from you tribal administrator

□  Certification of Income and Expenses- CSD43B

This form is to be completed by any household member who IS NOT WORKING!

Please also include:

 A current Notice of Action or Passport to Services if you receive SNAP/Cal-Fresh/Food Stamps, Cash Aid or General Relief.

42 U.S. Code §707 – Criminal penalty for false statements

(a) Whoever-
(1) knowingly and willfully makes or causes to be made any false statement or representation of a material fact in connection with the furnishing of items or

services for which payment may be made by a State from funds allotted to the State under this subchapter, or
(2) having knowledge of the occurrence of any event affecting his initial or continued right to any such payment conceals or fails to disclose such event with an

intent fraudulently to secure such payment either in a greater amount than is due or when no such payment is authorized, shall be fined not more than $25,000 or imprisoned for not more than five years, or both.
(b) For civil monetary penalties for certain submissions of false claims, see section 1320a–7a of this title.

(Aug. 14, 1935, Ch. 531, title V, §507, as added Pub. L. 97–35, title XXI, §2192(a), Aug. 13, 1981, 95 Stat. 824 .) To Report Fraud Call: 1-800-HHS-TIPS (1-800-447-8477)