Applicant Address Section

Enter Applicant Address Information:

• Salutation –How do you want to be addressed on formal communications? For example: Ms., Mrs. Dr.
• Last Name – Enter the last name of the Applicant.
• First name – Enter the first name of the Applicant.
• Middle Initial (MI) – Enter the middle initial of the Applicant.
• Street Address – Enter the full street number and name of your primary residence. 
• City – Enter the name of the municipality where the primary residence of your household (family) is located.
• State – Enter the name of the state where the primary residence of the household (family) is located.
• Application County – Enter the county of the household’s (family) primary residence. 
• Zip Code – Enter the Zip Code of the household’s (family) primary residence.
• Telephone number – Enter household’s (family) primary telephone number (include area code).
• May we contact you about your application? Answer Yes or No
• May we leave a detailed voice message? Answer Yes or No
• Mailing Address – Check this box if your mailing address is the same as above.

Mailing Address Section

• Mailing Address – Enter your full mailing address if it is different from the primary residence.
• Click the Next button.

• Is anyone in your household currently enrolled in any of the following program(s)? This information helps us determine eligibility and may help us to provide faster assistance because you have already provided information on your income and household in applying for these programs. Check all that apply:
  • LIHWAP – Select Yes or No
  • TANF – Select Yes or No
  • SNAP – Select Yes or No
  • SSI – Select Yes or No
  • Means-Tested Veterans Program – Select Yes or No
  • Other (please specify) – Select Yes or No
  • If you selected YES for other, provide a description in the “Other Description” field
• Add members of each family member - Please click the create button and include all specified details for all members of your household here (including yourself).
• Provide your household annual income
• Provide number of household members
• Please check each box in the table below for all sources of household income. Also attach/submit proof of all household income listed below. Proof of income for each household member for the last 60 days, such as a paystub, Social Security letter, child support letter, unemployment letter, selfemployment documentation, etc.)
  • Employment (Wages/Stub) – Select No or Yes
  • Social Security (Benefit Letter) – Select No or Yes
  • Child Support (Court Order) – Select No or Yes
  • Alimony (Court Order) – Select No or Yes
  • Unemployment (Benefit Letter) – Select No or Yes
  • Pension – Select No or Yes
  • Workers Compensation (Benefit Letter) – Select No or Yes
  • Self-Employment (Tax Return) – Select No or Yes
  • Zero Income (Affidavit) – Select No or Yes
  • Other (Please Specify) – Select No or Yes
  • If you selected YES for other, provide a description in the “Other Income Description” field.
• Upload Documentation
  • Non-LIHEAP recipients must upload proof of identity for each household member (SSN Card, if available), proof of income for each household member with income, AND recent (within last 60 days) water and sewer bill(s).
  • If your household is enrolled in LIHEAP, you must upload proof of identity for each household member (SSN Card, if available) and recent (within last 60 days) water and sewer bill(s).
  • Upload current documentation only. Documents cannot be older than 60 days from the application date in order to be accepted
• If applying on a laptop or computer, scan your documentation and upload the documentation to your laptop or computer.
• If you are using a mobile device, you can take pictures of the documents before you apply or during the application process.
• Click the Add files button.
• If applying on a laptop/computer: Click the Browse button and locate the files you want to upload. Select the files to upload and click the Open button. Then click the Add files button. Note: You can upload multiple files at the same time.
• On a mobile device, if you have already taken photos of the files: select the Choose Files button, select Photo Library, select the photos to upload and click the Add files button.
• On a mobile device, if you want to take a photo, select the Choose Files button, select Take Photo or Video option, take the photo, and click the Use Photo link. Click the Add files button.
• Notes/Explanation – If you need to provide additional information to further explain answers you have provided on this application, you may do so here.
• Click the Next button.

• Drinking Water Need – Required
  • My household drinking water has been shut off due to a past due bill.
    • If you selected this answer, please provide a drinking water shut off date.
  • My household drinking water services are on, but scheduled to be shut off.
  • My household drinking water services are on, but we need help paying future bills.
• Wastewater Need – Required
  • My household wastewater has been shut off due to a past due bill.
    • If you selected this answer, please provide a wastewater disconnection date.
  • My household wastewater services are on, but scheduled to be shut off.
  • My household wastewater services are on, but we need help paying future bills.
• Drinking Utility Company – Provide name of company
• Wastewater Utility Company – Provide name of company
• Drinking Water Account Number – Provide account number for Drinking Utility company
• Wastewater Account Number – Provide account number for Wastewater Utility company
• If your drinking and waste water company are the same, check the box.

• Read the Applicant Certification attestation.
• Indicate if anyone helped you complete this application.
• Applicant Certification – Please read, sign and date Applicant Certification (You must sign this certification – otherwise your application will not be processed).
  • Use your mouse (on a computer) or your finger (mobile device) to enter the Applicant Signature.
  • Click the Submit Signature button.
• When application is successfully submitted, you should be able to navigate back to the “American Rescue Plan Utility Debt Relief, LIHWAP, USF/LIHEAP & Weatherization” page and see your Application ID listed under My LIHWAP Applications.