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IMPORTANT NOTICE: This state of Illinois grantee agency, CEDA, is

requesting disclosure of information that is necessary to accomplish a complete application for:

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Low Income Home Energy Assistance Program (LIHEAP or Energy Assistance), including the Percentage of Income Payment Plan (PIPP) program

APPLICANT STATEMENT: I certify that the information I have provided is an accurate and complete disclosure of the requested information. I also certify that every household member in the application is a resident of Illinois. I authorize this agency to verify the information and contact my utility/fuel supplier, landlord, employer and/or other sources for verification or additional information and to exchange information contained in or otherwise used regarding my application and participation in LIHEAP.

For LIHEAP, I also authorize the Department of Commerce & Economic Opportunity and my utility/fuel supplier to share my usage and bill information during the twenty-four

(24) month period prior to and twelve (12) month period after the date of my application submittal and/or completion of LIHEAP services for the purpose of program evaluation and analysis.

I have received information outlining my appeal rights. I understand that filling out this application does not guarantee that my household will receive assistance. I understand I will be provided a copy of this application for my future reference. Applicant Name: Applicant Signature: Date: App ID: