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Be sure your correct and complete name and address is entered below. If incorrect, cross out and PRINT correctly in space provided below. YOU CAN ALSO APPLY ONLINE AT WWW.COMPASS.STATE.PA.US.  \nPhiladelphia CAO  \nLow-Income Home Energy Assistance Program (LIHEAP) 1348 W. Sedgley Ave.  \nPhiladelphia, PA 19132-2498  \nIf you do not understand these instructions, contact your local county assistance office.  \n1  \nPlease complete this section for the head of household.  \n*Use the codes from page 2 to help provide the details.  \n\n| Name (Include Last, First Middle Initial) |  |  | Date of Birth |  |  | Sex | Social Security Number |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| Home Address (Include Street, Apt. Number, City, State & ZIP Code+4) |  |  |  |  |  |  |  |  |\n| Mailing Address if different (Include Street, Apt. Number, City, State & ZIP Code+4) |  |  |  |  |  |  |  |  |\n| County You Live In | Phone Number:( ) | Citizenship* |  | Race (Optional)* | Ethnicity (Optional)* |  |  | Marital Status* |\n| If you are currently receiving Cash, Medical Assistance, or SNAP benefits, may we use the income you have on file?  Yes  No |  |  |  |  |  |  |  |  |\n\n3 Are You:  \n| DHS USE ONLY |  |  |  |\n| --- | --- | --- | --- |\n|  |  |  |  |\n|  | CRISIS | | CASH |\n|  |  |  |  |\n| Application Registration Number |  |  |  |\n| County |  |  |  |\n| District |  |  |  |\n| Record Number |  |  |  |\n| Worker I. D. |  |  |  |\n| ¨ Rejected ¨ Approved |  |  |  |\n| Date |  |  |  |\n\n\n| | Renting with heat included Renting with heat not included\u003Cbr>An unrelated roomer | | Renting subsidized housing/Section 8 housing with heat included\u003Cbr>Renting subsidized housing/Section 8 housing with heat not included |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- |\n|  |  |  | An owner or are you buying your home | | Other: | _______________________ |\n| If heat is included in your rent, attach a note from your landlord stating that heat is included and what type of heat is used. |  |  |  |  |  |  |\n\n4  \nWhat is your main heating source? Choose the type of energy that heats your home or is being used if your main heating source is not working. Attach a copy of your last bill or a statement from a utility or fuel dealer stating the type of fuel and that you are accepted as a customer.  \n\n| Electric\u003Cbr>| Fuel Oil | Coal | Natural Gas | Kerosene | Propane or Bottled Gas | Blended Fuel | Wood/Other |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n\n5  \n4a Do you need electricity to run your main heating source (secondary heat)?  Yes  No Check if any of the following apply and provide explanation if needed:  \n|  |  | Electricity is shut off Gas is shut off Ran out of fuel |  | Have a shut-off notice for electricity  Main heating source is not working Have a shut-off notice for gas Explain:  \u003Cbr>Will run out of fuel within 15 days   |\n| --- | --- | --- | --- | --- |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n|  |  |  |  |  |\n\nLow-Income Home Energy Assistance Program  \nPage 1 HSEA 1 7/20  \nWhich utility company or fuel dealer do you want to receive your LIHEAP grant? Write their name and address, and your account information.  \n\n| Name of Utility Company or Fuel Dealer\u003Cbr>Philadelphia Gas Works | Account Number |\n| --- | --- |\n| Address (Include Street, City, State & ZIP Code+4)\u003Cbr>800 W. Montgomery Ave., Philadelphia, PA 19122 | Name on Account |\n\nPlease list your electric company if not listed above  \n\n| Name of Electric Company | Account Number |\n| --- | --- |\n\nDo you use any other heating source in your home?  Yes  No  \nIf yes, please explain:    \nIf you are in subsidized/public housing, do you receive a utility allowance check? ¨ Yes ¨ No If yes, how much? $    \nDoes anyone in your household receive financial assistance for a disability? ¨ Yes","cbCaiuVDzpuw3BuH","https://ap.wps.com/l/cbCaiuVDzpuw3BuH","pdf",1048406,8,"English","# Application Instructions\n# Household Head Information\n## Basic Demographics and Benefits Authorization\n## DHS Use Only Section\n# Housing and Heating Details\n## Main Heating Source and Secondary Electricity\n## Utility Company / Fuel Dealer Information\n# Household Members Listing","[{\"question\":\"How do I submit the 2020-21 LIHEAP application and where do I sign?\",\"answer\":\"Complete all questions front and back and sign at the red “X”. Ensure the correct and complete name and address are entered below.\"},{\"question\":\"What information is required for the head of household?\",\"answer\":\"Provide details such as name, date of birth, sex, Social Security number, home and mailing addresses, county, phone number, citizenship, and optional race/ethnicity, plus marital status.\"},{\"question\":\"What heating-related details must be provided?\",\"answer\":\"Select the main heating source and indicate whether electricity is needed to run it as secondary heat. If applicable, attach required notes or copies such as the last bill or statements from a utility or fuel dealer.\"}]","2020-21 Low-Income Home Energy Assistance Program (LIHEAP) Application - Application Form | PDF",1789835074]