Senior Community liaison worker
Resume:
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.
LDSS-3421 (Rev. 5/17)
HOME ENERGY ASSISTANCE PROGRAM APPLICATION
PLEASE READ THE INSTRUCTIONS ATTACHED TO THE BACK OF THE APPLICATION. ANSWER ALL QUESTIONS. DO NOT WRITE IN THE SHADED AREAS. PLEASE PRINT CLEARLY, AND SIGN THE FORM ON PAGE 5. COMPLETE THE WHITE BOXES BELOW IN BLUE OR BLACK INK. 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: HOUSEHOLD COMPOSITION
APPLICANT INFORMATION
FIRST NAME MI LAST NAME
OTHER NAMES BY WHICH I HAVE BEEN KNOWN ARE:
OTHER NAME OTHER NAME
CURRENT STREET ADDRESS APT. # CITY
STATE ZIP CODE COUNTY LENGTH OF TIME AT THIS ADDRESS? YEARS MONTHS DAYTIME PHONE NUMBER WHERE I CAN BE REACHED (Area Code + Phone No.) BEST TIME TO CALL IF AN INTERVIEW IS NEEDED, I WOULD LIKE A:
Phone Interview In Person Interview
MY MAILING ADDRESS (IF DIFFERENT FROM ABOVE) IS:
ADDRESS APT. # CITY COUNTY STATE ZIP CODE
HAVE YOU EVER APPLIED FOR HEAP? YES NO IF YES, ENTER DATE OF MOST RECENT APPLICATION LIST EVERYONE INCLUDING YOURSELF WHO CURRENTLY LIVES IN THE SAME HOUSE (If no one else, write NONE UNDER YOUR NAME): CD LN FIRST NAME MI LAST NAME
DATE OF
BIRTH
SEX RELATION
TO ME
SOCIAL SECURITY
NUMBER
CITIZEN /
NATIONAL
OR
QUALIFIED ALIEN
BLIND
OR
DISABLED
MO. DAY YR. M/F
1 01
SELF
YES NO YES NO
1 02
YES NO YES NO
1 03
YES NO YES NO
1 04
YES NO YES NO
1 05
YES NO YES NO
1 06
YES NO YES NO
1 07
YES NO YES NO
If there are more members in your household, please attach a separate sheet of paper. Total Number in Household: DO YOU OR DOES ANYONE LIVING AT YOUR ADDRESS GET OR HAVE RECENTLY APPLIED FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)? YES NO If yes, who? CASE NUMBER DO YOU OR DOES ANYONE LIVING AT YOUR ADDRESS GET OR HAVE RECENTLY APPLIED FOR TEMPORARY ASSISTANCE?
YES NO If yes, who? CASE NUMBER LDSS-3421 (Rev. 5/17)
PAGE 2
SECTION 2: HOUSING – CHECK ONE BOX ONLY
HOMEOWNER RENTER
Single Family House or Mobile Home Private House, Apartment or Mobile Home
Multi-Family House; List Number of Units
Co-op/Condo Owner SUBSIDIZED RENT
Life Estate/Use Private Subsidized Housing
OTHER Public Housing Project or Senior Housing
I live with someone else and share expenses Public Subsidized Housing
I pay for a room
I pay room and board Do you receive a HUD utility allowance?
Permanent hotel/motel Yes If yes, how much $ No
Other living situation MY MONTHLY RENT OR MORTGAGE PAYMENT IS: $ NONE IF APPLICABLE, THE NAME OF THE APARTMENT BUILDING OR HOUSING PROJECT I LIVE IN IS: DO YOU OR DOES ANYONE IN YOUR HOUSEHOLD RECEIVE A SENIOR CITIZEN RENT INCREASE EXEMPTION (SCRIE)? YES NO SECTION 3: HEAT AND UTILITY INFORMATION
1. DO YOU PAY SEPARATELY FOR HEAT? Yes- Complete information below No My main source of heat is
Natural Gas Fuel Oil PSC Electric Coal or Corn
Wood/Wood Pellets Kerosene Propane or Bottle Gas Municipal Electric 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:
Please check if this is a landlord’s account number Your heating company’s name is: STREET ADDRESS CITY/TOWN STATE ZIP CODE
2. DO YOU PAY A SEPARATE ELECTRIC BILL FOR UTILITIES OTHER THAN HEAT? YES – Complete information below NO If yes, is the electric bill in your name? YES NO If No, name on the bill Your electric account number (if you have one) is:
Please check if landlord’s account number
Your utility company’s name is: Is electric necessary to run the furnace? YES NO Is electricity necessary to operate the thermostat in your apartment? YES NO 3. ARE BOTH HEAT AND ELECTRIC INCLUDED IN YOUR RENT? YES NO LDSS-3421 (Rev. 5/17)
PAGE 3
SECTION 4: HOUSEHOLD INCOME
REPORT ANY INCOME FOR ALL HOUSEHOLD MEMBERS. ALL AMOUNTS MUST BE REPORTED AS GROSS MONTHLY INCOME BEFORE ANY DEDUCTIONS. ATTACH ADDITIONAL SHEETS IF NECESSARY. CHECK YES OR
NO FOR EACH TYPE OF INCOME
IF YES, GIVE AMOUNT
ADDITIONAL INFORMATION WHO
RECEIVES?
YES NO
SOCIAL SECURITY AMOUNT
BEFORE MEDICARE PART B & D
GROSS MONTHLY AMOUNT
$
Indicate amount you pay for :
Medicare
Part B:
Medicare
Part D:
YES NO
SOCIAL SECURITY DISABILITY AMOUNT
BEFORE MEDICARE PART B & D
GROSS MONTHLY AMOUNT
$
Indicate amount you pay for :
Medicare
Part B:
Medicare
Part D:
YES NO
SUPPLEMENTAL SECURITY INCOME (SSI)
GROSS MONTHLY AMOUNT
$
YES NO WAGES
SUBMIT WAGE STUBS FOR THE PAST 4 WEEKS.
Note: Gross Weekly amounts are multiplied by
4.333333 to calculate the monthly amount.
Gross Bi-Weekly amounts are multiplied by
2.166666 to calculate the monthly amount.
WEEKLY $
BI-WEEKLY $
MONTHLY $
SEMI-MONTHLY
Employer
WEEKLY $
BI-WEEKLY $
MONTHLY $
SEMI-MONTHLY
Employer
WEEKLY $
BI-WEEKLY $
MONTHLY $
SEMI-MONTHLY
Employer
WEEKLY $
BI-WEEKLY $
MONTHLY $
SEMI-MONTHLY
Employer
YES NO
PENSION/RETIREMENT Private and/or government
GROSS MONTHLY AMOUNT
$
Source of Pension
YES NO
VETERAN’S BENEFITS
GROSS MONTHLY AMOUNT
$
YES NO
DISABILITY private or NYS
GROSS WEEKLY AMOUNT
$
Source
YES NO
CONTRIBUTION from someone outside the household
GROSS MONTHLY AMOUNT
$
Name of Contributor
YES NO
CHILD SUPPORT
GROSS WEEKLY AMOUNT
$
Source
YES NO
ALIMONY/SPOUSAL SUPPORT including payments for
mortgage, utility bills, etc.
GROSS MONTHLY AMOUNT
$
Source
YES NO
RENTAL INCOME apartment, garage, land, etc.
GROSS MONTHLY AMOUNT
$
Type of Rental
YES NO
ROOM/BOARD (received) etc.
GROSS MONTHLY AMOUNT
$
Name of Room/Boarder
YES NO
WORKER’S COMPENSATION
GROSS WEEKLY AMOUNT
$
YES NO
UNEMPLOYMENT BENEFITS
GROSS WEEKLY AMOUNT
$
Start Date:
End Date:
YES NO
Income from savings, checking, CDs, money market
accounts, stocks, bonds, securities. IRA, annuity, and 401K distributions.
ENTER INFORMATION ON NEXT PAGE
YES NO
IS THERE ANY OTHER INCOME FROM ANY OTHER
SOURCE? ATTACH EXPLANATION
AMOUNT
$
Source
WHO RECEIVES
YES NO
SELF-EMPLOYMENT INCOME
TYPE OF BUSINESS
If yes, you may choose to have your 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
LDSS-3421 (Rev. 5/17) PAGE 4
IS THERE ANYONE IN YOUR HOUSEHOLD AGE 18 OR OLDER WHO DOES NOT HAVE ANY INCOME FROM ANY SOURCE?
YES, list members with no income: NO
IS THERE ANYONE IN YOUR HOUSEHOLD WHO IS A FULL-TIME DEPENDENT HIGH SCHOOL OR COLLEGE STUDENT?
YES, list member(s): NO
INTEREST AND INVESTMENT INCOME
LIST EACH ACCOUNT SEPARATELY. ATTACH ADDITIONAL SHEETS IF NECESSARY.
AMOUNT RECEIVED
YEAR-TO-DATE
SOURCE
INTEREST from savings, checking, CDs, money market accounts, etc. $ Name of Bank INTEREST from savings, checking, CDs, money market accounts, etc. $ Name of Bank
INTEREST from savings, checking, CDs, money market accounts, etc. $ Name of Bank
INTEREST from savings, checking, CDs, money market accounts, etc. $ Name of Bank
DIVIDENDS from stocks, bonds, securities, etc. $ Source of Dividends DIVIDENDS from stocks, bonds, securities, etc. $
Source of Dividends
DIVIDENDS from stocks, bonds, securities, etc. $
Source of Dividends
DIVIDENDS from stocks, bonds, securities, etc. $
Source of Dividends
DISTRIBUTIONS from IRA, 401K, annuity, etc. $
Source of Distributions
DISTRIBUTIONS from IRA, 401K, annuity, etc. $
Source of Distributions
DISTRIBUTIONS from IRA, 401K, annuity, etc. $
Source of Distributions
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 season unless revoked by you. Each HEAP season 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 and phone number: PLEASE SIGN APPLICATION ON PAGE 5
LDSS-3421 (Rev 5/17) PAGE 5
SECTION 5: 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 give us in this way, 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. If you or anyone in your household does not have a Social Security Number, a Social Security Number must be applied for at the U.S. Social Security Administration.
Read the Important Information Below
I swear and/or affirm that the information given on this application and subsequent phone interviews 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. SIGN HERE:
X
DATE SIGNED
NAME OF PERSON, IF ANY, WHO ASSISTED YOU:
PHONE NUMBER:
LDSS-3421 (Rev. 5/17) PAGE 6
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
LN HOUSEHOLD MEMBER’S NAME DOCUMENTATION
01
02
03
04
05
06
IS ANYONE IN THE HOUSEHOLD VULNERABLE? Under the age of 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 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 REGULAR BENEFIT
(EMERGENCY USE PART B)
Gross Bi-Weekly Income x 2.166666
Gross Weekly Income x 4.333333
TOTAL 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
Benefit $
Application compared to previous information
No prior application No Changes WMS Inquiry Changes verified How:
Pended START: END:
APPROVED DENIED
CERTIFYING AGENCY
WORKER’S SIGNATURE/DATE
SUPERVISOR’S SIGNATURE/DATE
CONSENT TO WITHDRAW
I CONSENT TO WITHDRAW MY APPLICATION SIGN HERE X I UNDERSTAND THAT I MAY REAPPLY FOR HEAP BENEFITS AT ANY TIME DURING THE PERIOD THAT HEAP APPLICATIONS ARE BEING ACCEPTED
LDSS-3421 (Rev. 5/17) PAGE 7
AGENCY USE ONLY
NOTES AND INCOME CALCULATION WORKSHEET
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.
LDSS-3421 (Rev. 5/17) Page 1
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 www.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. 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 http://www.otda.ny.gov or by calling our toll free number at 1-800-***-****. 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. LDSS-3421 (Rev. 5/17) Page 2
INSTRUCTIONS FOR COMPLETING THE APPLICATION:
Complete all non-shaded areas 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 the box on page one. Completion of this section does not mean you will be required to have an interview.
All applications for heating equipment repair or replacement must have an in person 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 on line 1. If you live alone, write the word “none” on line 2.
Citizen /Alien Information:
In order to receive HEAP you must be a U.S. citizen, Qualified Alien, or U.S non-citizen national. For additional information on what constitutes a Qualified Alien 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 http://www.otda.ny.gov. Why do I need to provide Social Security numbers for everyone? Social Security numbers are required for all household members. 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 you leave this section blank for any household member, your application cannot be processed but will be pended for further information. This information may also 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 three (3) 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 6 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. LDSS-3421 (Rev. 5/17) Page 3
What does authorized representative mean?
An authorized representative is a person who may act as your agent for HEAP purposes as listed 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. Make sure to SIGN and date the application. The application must be signed by the person who has the heating bill in their name, or who pays the bill if it is in someone else’s name. If heat is included in the rent, the primary tenant must complete and sign the application.
Motor Voter Registration
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. 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
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 6 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 on Page 1 of your application. All applications for heating equipment repair or replacement must be in person with full documentation. WHERE TO 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: http://www.otda.ny.gov.
MY BENEFITS
You may apply for HEAP online by going to https://www.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 https://www.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 https://www.mybenefits.ny.gov . Additional information about HEAP and other human services programs can be found at https://www.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. LDSS-3421 (Rev. 5/17) Page 4
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. 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 than thirty (30) business days since program opening if the certifier received your application prior to program opening) and you have not been told of the eligibility decision. If you would like a conference, you should ask for one as soon as possible. At the conference, if it is discovered that a wrong decision was made, or if because of information you provide, the decision has changed our original decision, corrective action will be taken.
If you would like a conference, please contact your Local Department of Social Services. This is only for requesting a conference. It is not how you ask for a fair hearing. If you ask for or have a conference, you are still entitled to a fair hearing.
The Office of Temporary and Disability Assistance (OTDA) policy issuances and manuals are posted on the OTDA website at otda.ny.gov/legal. These issuances and manuals are available to you or your representative to determine whether a fair hearing should be requested or to prepare for a fair hearing. In addition, upon request to your local social services district, specific OTDA policy issuances and manuals will also be available to assist you or your representative. If you live anywhere in New York State, you may request a Fair Hearing by telephone, fax, online, or by writing to the address below:
Telephone: Statewide toll free request number is 800-***-****. Please have the notice, if any, with you when you call. Fax: your Fair Hearing request to: 518-***-****
Online: Complete online request form at http://www.otda.ny.gov/oah/ LDSS-3421 (Rev. 5/17) Page 5
In writing: For notices, fill in the supplied space and send a copy of the notice, or write to: NYS Office of Temporary and Disability Assistance
Office of Administrative Hearings
P.O. Box 1930
Albany, NY 12201-1930
If you request a fair hearing, NYS will send you a notice of the time and place of the hearing. You have the right to be represented by legal counsel, a relative, friend, or other person, or to represent yourself. At the hearing, your attorney or other
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