LDSS-**** (Rev. */**)

HOME ENERGY ASSISTANCE PROGRAM APPLICATION

If you are blind or seriously visually impaired and need this application in an alternative format, you may request one from your social services district. For additional information regarding the types of formats available and how you can request an application in an alternative format, see the attached instructions or visit www.otda.ny.gov. If you are blind or seriously visually impaired, would you like to receive written notices in an alternative format? Yes No If Yes, check the type of format you would like:

Large Print Data CD Audio CD

Braille, if you assert that none of the other alternative formats will be equally effective for you.

If you require another accommodation, please contact your social services district.

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LDSS-3421 (Rev 5/23) New York State Office of Temporary and Disability Assistance Home Energy Assistance Program Application

Please read the instructions attached to the back of the application. Answer all questions. Please print clearly and sign the form in Section 9.

Contact the agency above if you need help

Agency Use Only

DSS OFA/Alternate Certifier

Date Received

Date Received

Agency Use Only

Application Date

Office Unit ID Worker ID Case Type Case Number Registry Number Vers. Case Name

Regular Heating Eqpt Cooling

Emergency Clean & Tune Other

Section 1: Applicant Information

Gender Identity, Ethnicity, and Race are optional. For gender identity, please use the following: Male, Female, Non-binary, X, Transgender, Prefer Not to Say, or Different Identity (please describe).To identify race, please use the following: American Indian or Alaska Native (I), Asian (A), Black or African American (B), Multi-race (M), Native Hawaiian or Other Pacific Islander

(P), White (W), Other (O).

1. First Name: MI: Last Name: Date of Birth: Sex: Male Female X Gender Identity (optional): Social Security Number: Citizen/US National or Qualified Non-Citizen Yes No Ethnicity: Hispanic, Latino or Spanish Origin (Optional) Yes No Race: (Optional) 2. Street Address: County: City: State: Zip: Length of time at this address: 3. Mailing address if different from above: 4. Daytime phone number: Best Time to Call: 5. Other names by which I have been known are: 6. Have you ever applied for HEAP? Yes No If Yes, what was the date of your last application? 7. If an interview is required, please select your preference: phone interview in-person interview 8. What language do you prefer to speak: What language do you prefer to read: 9. Will you require a free interpreter? Yes No

10. Do you or does anyone living at your address get or have recently applied for Supplemental Nutrition Assistance Program

(SNAP) or Temporary Assistance (TA)? Yes No If Yes, who? Case number:

11. Is anyone in the household disabled or blind? Yes No If Yes, who? 12. Is anyone in your household a veteran? Yes No If Yes, who? 2

LDSS-3421 (Rev 5/23) New York State Office of Temporary and Disability Assistance Section 2: Household Information

List the people who live with you. Attach additional sheets as needed. Gender Identity, Ethnicity, and Race are optional. For gender identity, please use the following: Male, Female, Non-binary, X, Transgender, Prefer Not to Say, or Different Identity

(please describe).To identify race, please use the following: American Indian or Alaska Native (I), Asian (A), Black or African American (B), Multi-race (M), Native Hawaiian or Other Pacific Islander (P), White (W), Other (O). First Name: MI: Last Name: Date of Birth: Sex: Male Female X Gender Identity (optional): Relationship to applicant: Social Security Number: Citizen/US National or Qualified Non-Citizen Yes No Ethnicity: Hispanic, Latino or Spanish Origin (Optional) Yes No Race: (Optional) First Name: MI: Last Name: Date of Birth: Sex: Male Female X Gender Identity (optional): Relationship to applicant: Social Security Number: Citizen/US National or Qualified Non-Citizen Yes No Ethnicity: Hispanic, Latino or Spanish Origin (Optional) Yes No Race: (Optional) First Name: MI: Last Name: Date of Birth: Sex: Male Female X Gender Identity (optional): Relationship to applicant: Social Security Number: Citizen/US National or Qualified Non-Citizen Yes No Ethnicity: Hispanic, Latino or Spanish Origin (Optional) Yes No Race: (Optional) First Name: MI: Last Name: Date of Birth: Sex: Male Female X Gender Identity (optional): Relationship to applicant: Social Security Number: Citizen/US National or Qualified Non-Citizen Yes No Ethnicity: Hispanic, Latino or Spanish Origin (Optional) Yes No Race: (Optional) First Name: MI: Last Name: Date of Birth: Sex: Male Female X Gender Identity (optional): Relationship to applicant: Social Security Number: Citizen/US National or Qualified Non-Citizen Yes No Ethnicity: Hispanic, Latino or Spanish Origin (Optional) Yes No Race: (Optional) First Name: MI: Last Name: Date of Birth: Sex: Male Female X Gender Identity (optional): Relationship to applicant: Social Security Number: Citizen/US National or Qualified Non-Citizen Yes No Ethnicity: Hispanic, Latino or Spanish Origin (Optional) Yes No Race: (Optional) Total number of household members:

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LDSS-3421 (Rev 5/23) New York State Office of Temporary and Disability Assistance Section 3: Housing Information

1. Select the box that most accurately describes your housing situation Homeowner Renter

Single family house or manufactured home Private house, apartment, or manufactured home Multi-family house: list number of units

Co-op/Condo owner Subsidized Rent

Life Estate/Life Use Private subsidized housing

Public housing project or senior housing

Other Public subsidized housing

I live with someone else and share expenses

I pay for a room

I pay room and board

Permanent hotel/motel

Other living situation:

2. My monthly rent or mortgage payment is: $ None 3. If applicable, the name of the apartment building or housing complex you live in: Section 4: Heat and Utility Information

1. Do you pay for heat? Yes- Please complete the information below No My main source of heat is:

Natural Gas Fuel Oil Electric Coal or Corn

Wood/Wood Pellets Kerosene Propane or Bottle Gas Other My fuel tank is: Individual Tank Metered Tank

Is the heating bill in your name? Yes No

If no, name on the bill: Relationship to you: Are you directly responsible to pay the bill? Yes No Your heating account number is: Your heating company’s name: Your heating company’s address: 2. Do you pay a separate electric bill for utilities other than heat? Yes- Please complete the information below No Is the electric bill in your name? Yes No If no, name on bill: Your electric account number is: Your electric company’s name: Your electric company’s address: Is electricity necessary to run the furnace? Yes No Is electricity necessary to operate the thermostat in your apartment: Yes No 3. Is heat included in your rent? Yes No

4. Is electricity included in your rent? Yes No

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LDSS-3421 (Rev 5/23) New York State Office of Temporary and Disability Assistance Section 5: Household Income

Provide income information for all members of the household, including yourself, for the previous month. Applicant must provide proof of income. Applicant may attest to income information on behalf of other household members. Source of income is the Employer Name, Social Security, Social Security Disability, Child Support, Rental Income, Unemployment, etc. Frequency is how often you are paid: Weekly, Monthly, Bi-weekly, etc. Gross amount is amount paid to you before deductions. If receiving Medicare, please enter gross amount and indicate amounts paid for Part B and/or D. Name of Who Receives Source of Income Frequency Gross Amount Medicare Part B and/or D $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Is there anyone in your household age 18 or older who does not have any income from any source? Yes No If Yes, list all members with no income: Is there anyone in your household who is a full-time dependent high school or college student? Yes No If Yes, list members: Section 6: Other Sources of Income

1. Do you receive rental income? Yes No If Yes, what is the gross monthly amount? $ 2. Do you receive room/board? Yes No If Yes, what is the gross monthly amount? $ 3. Do you receive self-employment income? Yes No Type of business? If yes, you may choose to have your rental and/or self-employment income calculated based on your filed federal tax return for the current year or prior tax year if you have not yet filed for the current year, including all applicable schedules, or based on the three (3) months prior to your application.

Please choose one method: Filed Federal Tax Return Three Months 5

LDSS-3421 (Rev 5/23) New York State Office of Temporary and Disability Assistance 4. Did your household receive any interest or investment income from savings, checking, CD’s, money market accounts, stocks, bonds, securities, or distributions from IRA, 401K, or annuities, etc.? Yes No If Yes, please enter below. List each account separately.

Type of Account Amount Received Year-to-Date Name of Bank/Source of Dividend or Distribution $ $ $ 5. Is there any other income from any other source? Yes No Source: Who receives? What is the gross monthly amount? $ Section 7: Important Notices

Important Notice

You should be aware that there is limited money available for HEAP Benefit payments. Once available money is exhausted, no benefits will be issued, Therefore, it is strongly recommended that you complete and submit your application as soon as possible.

Personal Privacy Law-Notification to Clients

The State’s Personal Privacy Protection Law, which took effect September 1, 1984, states that we must tell you what the State will do with the information you give us about yourself and your family. We use the information to find out if you are eligible for the Home Energy Assistance Program and, if so, for how much. The section of the Law that gives us the right to collect the information about you is Section 21 of the Social Services Law. To make sure that you are getting all of the assistance you and your family are legally entitled to receive, we check with other sources to find out more about the information you have given us. For example:

• We may check to find out if you or anyone in your household were working. We do this by sending your name and Social Security Number to the State Department of Taxation and Finance, and also to known employers, to tell us whether you worked and, if so, how much you made.

• We may ask the State to check with the Unemployment Insurance Division to see if you or anyone in your household were getting unemployment benefits.

• We may check with banks to make sure we know about any income you or anyone in your household may have received. Besides using the information you provided in this application, the State also uses the information to prepare statistics about all the people receiving Home Energy Assistance. This information is used for program planning and management. The information is used for quality control by the State to make sure local districts are doing the best job they can. It is used to verify who your energy supplier is and to make certain payments to such vendors. Your failure to provide us with the information we need may prevent us from finding out if you are eligible for assistance and we may then have to deny your application. This information is kept by the Commissioner, Office of Temporary and Disability Assistance, 40 North Pearl Street, Albany, New York 12243-0001. Do not send your application to this address. 6

LDSS-3421 (Rev 5/23) New York State Office of Temporary and Disability Assistance Section 8: Authorized Representative

You can designate someone who knows your household circumstances to be your authorized representative. Your Authorized Representative may: complete and file your HEAP application, contact the agency, and speak with your worker, have access to eligibility information in your case file, complete all forms for you, provide documentation, appeal agency decisions. You must still sign this application. The Authorized Representative designation will remain in effect for the current HEAP program year unless revoked by you. Each HEAP program year you will be asked if you want to designate an Authorized Representative.

I would like to designate an authorized representative. Yes - Complete information below No Name of authorized representative: Address: Phone number: Section 9: Consent and Signature

Read the Important Information Below

I swear and/or affirm that the information given on this application is true and correct. I realize that any false statements or other misrepresentation knowingly made by me in connection with this application and subsequent requests for HEAP assistance may result in my being found ineligible for the assistance paid to me or on my behalf. Additionally, any false statement or misrepresentation knowingly made by me for purposes of obtaining assistance under this program may result in an action against me which may subject me to civil and/or criminal penalties. Consent

I understand that by signing this application/certification, I consent to any investigation to verify or confirm the information I have given and other investigation by any authorized government agency in connection with this and any other requests for Home Energy Assistance Program (HEAP) benefits. I also consent to allow the information provided on this application to be used in referrals to available weatherization assistance programs and my utility company’s low-income programs. I understand that the State will use my Social Security Number to verify with my home energy vendors the receipt of HEAP. This authorization also includes permission for any of my home energy vendors (including my utility) to release certain statistical information, including but not limited to, my electricity usage, electricity cost, fuel consumption, fuel type, annual fuel cost and payment history to the Office of Temporary and Disability Assistance, the local Social Services District and the United States Department of Health and Human Services for the purposes of Low Income Home Energy Assistance Program

(LIHEAP) performance measurement.

To get HEAP, all questions must be answered, and your application must be signed and dated below. Name (print) Signature Date: Name of person, if any who assisted you: Phone number: 7

LDSS-3421 (Rev. 5/23)

Agency Use Only

Application Type: Full Documentation Simplified

Vendor

Account Number Vendor Code Vendor Relationship:

Current Bill/Vendor Statement

Collateral Contact

Identity of Household Members

Household Member’s Name Documentation

Is anyone in the household vulnerable? Under age 6 Age 60 or older Permanently Disabled Who: Documentation: Residence – Check type of documentation obtained

Current Rent Receipt w/Name & Address Water, Sewage, or Tax Bill Mortgage Payment Book/Receipts w/Address Homeowner’s/Renter’s Insurance Policy Copy of Lease w/Address Utility Bill Other Income Documentation/Calculation

Categorically Income Eligible: TA SNAP Code A SSI

Comments, resolution activities, income calculation/documentation, verification of emergency for expedited regular benefit, vendor contract, etc. Show all calculations. Use next page if necessary. Gross Bi-Weekly Income x 2.166666

Gross Weekly Income x 4.333333

Total Monthly Income $

Separate Heat (check one)

Oil Kerosene LP Gas Natural Gas

Wood Wood Pellets Coal/Corn PSC Electric

Municipal Electric

Heat Included in Rent

Payment to Household

Payment to Utility

Interview Completed: Yes, Date No N/A

Application compared to previous information

No prior application No Changes WMS Inquiry Changes verified How: Pended:

Yes No

Pend Start Date: Pend End Date:

Approved, Benefit $ Denied, Reason

Certifying Agency

Worker’s Signature Date:

Supervisor’s Signature Date:

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LDSS-3421 (Rev. 5/23)

Agency Use Only

Notes and Income Calculation

Federal Reporting Status of Home Energy Service

The household has one or more of the following - Check all that apply A disconnect notice. Company Name: Disconnection from service. Company Name: Less than tank of fuel. Company Name: Less than a 10-day supply of fuel. Company Name: Out of fuel. Company Name: A non-working furnace/boiler/heat system that needs replacement. Electricity as supplemented heating fuel.

Wood as supplemental heating fuel.

Other supplemental heating fuel.

Central air conditioning.

A window or wall air conditioner.

Consent to Withdraw

Only sign here if you want to withdraw your application and do not want to apply for HEAP. I consent to withdraw my Application.

Signature I understand that I may reapply for HEAP benefits at any time during the period that HEAP applications are being accepted.

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LDSS-3421 (Rev. 5/23)

New York State Home Energy Assistance Program (HEAP) Application Instructions

If you are blind or seriously visually impaired and need an application or these instructions in an alternative format, you may request them from your social services district (SSD). The following alternative formats are available:

• Large print;

• Data format (a screen reader-accessible electronic file);

• Audio format (an audio transcription of the instructions or application questions); and

• Braille, if you assert that none of the alternative formats above will be equally effective for you.

Applications and instructions are also available for download in large print, data format and audio format from otda.ny.gov. Please note that applications are available in audio format and Braille solely for informational purposes. In order to apply, you must submit an application in written, non-alternative format. If you have any disabilities that prevent you from completing this application and/or from waiting to be interviewed, please notify your SSD. The SSD will make every effort to provide a reasonable accommodation to address your needs.

If you require another accommodation, or need other help completing this application, please contact your SSD. We are committed to assisting and supporting you in a professional and respectful manner.

Alternative Formats:

Check “Yes” or “No” to indicate whether you are blind or seriously visually impaired and would like to receive written notices in an alternative format. If "Yes," check the type of format you would like. Alternative formats are available in large print, data CD, audio CD, or Braille, if you assert that none of the other alternative formats are equally effective for you. If you require another accommodation, or need other help completing this application, please contact your SSD. 10

LDSS-3421 (Rev. 5/23)

Important Information About Program Dates

HEAP benefits are only available when the program is open. The opening and closing dates are determined for each program year. Opening dates for the regular benefit and the emergency benefit components may be different. Information on the opening and closing dates for this year’s program can be found on the OTDA website at otda.ny.gov or by calling our toll-free number at 1-800-***-****. Instructions for completing the application:

Complete Sections 1 through 9 and answer all questions. Who should complete and sign the application?

The application should be completed by the person who has primary and direct responsibility for payment of the heating bill or the primary tenant if heat is included in the rent. What address should I list?

You must list your current address. This must be your permanent and primary residence. Why do you need my daytime phone number?

It is important to list a phone number where you can be reached. This will assist in timely processing of your application if additional information is required. Will I need an interview?

Some applicants may be required to have an interview. You may choose to have a phone interview or to have an in-person interview. Please indicate your interview preference in Section 1. Completion of this section does not mean you will be required to have an interview. Who should I list as household members?

List everyone who lives in your house, even if they are not related to you or contributing financially to your household. You may be required to provide proof of identity for all household members. List yourself first in Section 1. All additional household members should be listed in Section 2. If there are more members in your household, please attach a separate sheet of paper. If you live alone, proceed to Section 3.

Gender Identity (Optional):

New York State ensures your right to access State benefits and/or services regardless of sex, gender identity or expression. You must report your sex and the sex of all household members as male, female or X. The sex you report here must be the same as what is currently on file with the United States Social Security Administration. The sex you report is needed to process your application. It will not appear on any benefit card you may receive or any other public-facing document. Gender identity is how you perceive yourself and what you call yourself. Your gender identity can be the same as or different from your sex assigned at birth. Gender identity is not required for this application. If your gender identity, or the gender identity of anyone in your household, is different than the sex you report for that person and you would like to provide that person’s gender identity, print

“Male”, “Female”, “Non-Binary”, “X”, “Transgender”, “Prefer Not to Say” or “Different Identity” in the space provided. If you print “Different Identity”, you may choose to describe that person’s gender identity in the space provided.

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LDSS-3421 (Rev. 5/23)

Race/Ethnicity Information (Optional):

Providing this information is voluntary. It will not affect the eligibility of the persons applying or the level of benefits received. The reason for requesting this information is to ensure that program benefits are distributed without regard to race, color, or national origin. To identify race, please use the following: American Indian or Alaska Native (I), Asian (A), Black or African American (B), Multi-race (M), Native Hawaiian or Other Pacific Islander (P), White (W), Other (O). Citizen/Qualified Non-Citizen Information:

In order to receive HEAP, a member of your household, must be a U.S. Citizen, Qualified Non-Citizen, or U.S Non-Citizen National. For additional information on what constitutes a Qualified Non-Citizen or U.S. Non-Citizen National, please contact the New York State Office of Temporary and Disability Assistance hotline at 1-800-***-**** or visit the OTDA website at otda.ny.gov. Why do I need to provide Social Security numbers?

Social Security Numbers must be listed for all household members that have a Social Security Number. The information is validated with data from the Social Security Administration. If any member does not have a Social Security Number but has applied for one, write the word “applied” in the Social Security Number box. If a household member does not have a Social Security Number, write the word “none” in the Social Security Number box. This information may be used to perform data matches with other state and federal agencies for the purposes of verifying your household’s HEAP eligibility. Housing Information:

Please check the box that most accurately represents your housing situation. Heating Situation:

Make sure to answer all four (4) questions

How should I complete the income section? Will I need to provide proof? List ALL income for all household members. All amounts should be entered as gross income prior to any deductions. Deductions include, but are not limited to: income taxes, child support, garnishments, health insurance, and union dues. You are required to submit documentation of all earned income, including self-employment and rental income. You may be required to provide proof of other income. Please see page 15 of the application instructions for specific types of acceptable documentation. Do not submit originals, they will not be returned. Eligibility will be based on your household’s gross monthly income for the month of application.

Please enter the amount of your Social Security before any deductions for Medicare. List separately the amounts that you pay for Medicare Part B and/or D. Amounts for Medicare Parts B and D are excluded as income.

Enter only the interest or dividend portions of bank accounts, CDs, stocks, bonds or other investment income. List each account separately. If you need more space, attach additional sheets. Enter the amount received for the year to date.

What does authorized representative mean?

An authorized representative is a person who may act as your agent for HEAP purposes as listed in Section 8 on the application. Authorized representative status is for the current program only and you may revoke it at any time during the program by submitting a statement to your local social services district. Since this person may be providing information on your behalf, it should be someone who knows your circumstances.

Motor Voter Registration (Optional)

Please include the Motor Voter form with your application. Complete this form if you are not registered to vote and you want to register. This does not affect your HEAP eligibility or benefit amount. 12

LDSS-3421 (Rev. 5/23)

What will I need to apply?

New applicants will need to include the following documentation along with your application:

• Proof of each household member’s identity

• A valid Social Security Number for each household member that has a Social Security Number

• Proof of residence

• A fuel and/or utility bill if you pay for heat or proof that you pay rent which includes heat

• Documentation of income for all household members Please see page 15 of the application instructions for specific types of acceptable documentation. In addition, new applicants will also need to have an interview; and you can choose either a phone interview or an in-person interview. However, if you do choose a phone interview, please include a working phone number and the best time to contact you for a phone interview in Section 1 of your application.

Where do I apply:

You must apply in the county in which you currently reside. You can apply in person or mail in your application at the address stamped at the top of the application or can find other local certifiers by checking our website at: otda.ny.gov.

myBenefits:

You may apply for HEAP online by going to mybenefits.ny.gov. Once your application for HEAP is submitted, you can check the status of your application on-line by using your secure online account at mybenefits.ny.gov. If your application is approved the amount of the benefit is provided. You may be eligible for food assistance. Check your eligibility and apply for SNAP at mybenefits.ny.gov. Additional information about HEAP and other human services programs can be found at mybenefits.ny.gov. How will my benefit be paid?

If you are approved and you pay for heat, your payment will be sent to your heating fuel vendor. Your eligibility notice will include the name of the vendor. If the vendor listed is not correct, notify the local social services district immediately. In some cases, your benefit will be paid to your electric company if heat is included in your rent. Your notice will tell you the amount of the benefit, how it will be paid, and how it was calculated.

Vendors are not permitted to make deliveries until payment is received or until instructed to do so by the local Social Services District. Benefits may not be applied to prior deliveries for deliverable fuel sources. If you are in need of fuel before your vendor has received notification or payment, you must contact your local social services district.

Regular HEAP benefits are intended to be a one-time supplement to your annual energy costs and are not intended to replace your personal payments. You must continue to pay your energy bills. What is a HEAP Emergency?

• You are out of fuel or have less than tank of oil, kerosene or propane, or less than a ten (10) day supply of other deliverable heating fuel.

• Your natural gas or electric heat has been shut off or is scheduled to be shut off.

• Applicant owned heating equipment is not working. What if I have an emergency?

HEAP benefits can assist with the following emergencies:

• You are out of fuel or have less than tank of oil, kerosene, or propane, or less than a ten (10) day supply of other deliverable heating fuel.

• Your natural gas or electric heat has been shut off or is scheduled to be shut off.

• Applicant owned heating equipment is not working. 13

LDSS-3421 (Rev. 5/23)

If you have a heating emergency and have applied for, but have not received, your regular benefit, you should contact your local social services district after the program opens. Whenever possible, regular HEAP benefits are used first to resolve an energy emergency. Do not wait until you are out of heating fuel or your gas/electric service is off to request assistance. If your utility service is terminated, your utility company is not required to restore your service even if you are eligible for a HEAP benefit. Fair Hearings:

You have certain rights when filing your HEAP application. You have the right to be told if your application is approved or denied within thirty (30) business days of the date that the HEAP certifier receives your completed and signed application.

The processing time for applications will not begin until program opening even though you may have received an application prior to the program opening date as a part of our outreach effort. You have the right to request a conference and/or a fair hearing if it has been more than thirty (30) business days since the HEAP certifier received your signed and completed application (or it has been more

Contact this candidate