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LIHEAP Intake Form FY2016 - maturacommunityaction maturaact

LIHEAP Intake Form FY2016 - maturacommunityaction maturaact 2025

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The document is an intake form from the Iowa Department of Human Rights, Division of Community Action Agencies, designed to collect personal and financial information from individuals applying for assistance programs such as LIHEAP (Low Income Home Energy Assistance Program) and other community services. It includes sections for household details, income sources, housing status, and consent for information sharing related to energy assistance.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in your personal information, including your last name, first name, and middle initial. Ensure accuracy as this information is crucial for processing your application.
Next, provide your address details. If your mailing address differs from your street address, make sure to fill that section accurately.
In the income section, list all sources of income for each household member. Specify the rate of pay and total income for both three-month and twelve-month periods.
Indicate your heating service provider and account details. This information is essential for verifying your energy needs.
Complete the housing type and status sections by checking the appropriate boxes that apply to your situation.
Finally, review all entries for accuracy before signing and dating the form at the bottom. Your signature confirms that all provided information is true.

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