LIHEAP Invoice Schedule

Form HM-2

Week Ending Faxed Invoice to KACA Original Received

(due by 4:00 p.m., EST) by KACA

November 12, 1999 November 16, 1999 November 19, 1999

November 26, 1999 November 30, 1999 December 3, 1999

December 10, 1999 December 14, 1999 December 17, 1999

December 24, 1999 December 28, 1999 December 31, 1999

January 7, 2000 January 11, 2000 January 14, 2000

January 21, 2000 January 25, 2000 January 28, 2000

February 4, 2000 February 8, 2000 February 11, 2000

February 18, 2000 February 22, 2000 February 25, 2000

March 3, 2000 March 7, 2000 March 10, 2000

March 17, 2000 March 21, 2000 March 24, 2000

March 31, 2000 April 4, 2000 April 7, 2000

April 14, 2000 April 18, 2000 April 21, 2000

April 28, 2000 May 2, 2000 May 5, 2000

May 12, 2000 May 16, 2000 May 19, 2000

 

 

 

 

The Reconciliation Report (to be completed by Agency Fiscal Dept.) is due June 1, 2000.

The Final Report (to be completed by Agency Program Dept.) is due July 15, 2000.

Revised 9/27/99

 

 

TO: Agency

 

 

LIHEAP RECONCILIATIONS

 

Listed below are the total payments made to your agency as of ____________________. Please complete the final expenditure section and return this form in the enclosed envelope by June 1st. Attached is a breakdown of our payments to you.

Payments to you agency through ___________________

Crisis Benefits _______________

Subsidy Benefits _______________

Other/Emergency _______________

Admin. _______________

Total _______________

 

Final Expenditure Report

Crisis Benefits _______________(includes space heaters)

Subsidy Benefits _______________

Other/Emergency _______________

Admin. _______________

Total _______________

 

 

Revised September 27, 1999

 

 

Form HM - 4

 

LIHEAP - BATCH TICKET

(To be submitted with paper applications

and computer data disks)

 

Subsidy __________ Approved __________

Crisis __________ Denied __________

Other __________

 

Agency Name: _________________________________________

Date ________________________ Batch # ___________________

 

Submitted for Week of _______________________ to ________________________

(For paper applications, submit one ticket for the calendar week (Monday through Friday) except when the calendar week falls two months, then submit two batch tickets. All applications for the week are due within 7 days.)

Enclosed Applications:

# of Applications __________________________

Dollar Amount Obligated __________________________

I certify that the above information is correct to the best of my knowledge.

 

____________________________________ __________________________

Authorized Signature Date

______________________________________________________________________________

For KACA Use Only:

Date Batch Received __________ Number of applications __________

Date sent to data processing __________ Box Number __________

Date returned from data processing __________

Revised 8/98

Contingency Fund Request Form

 

 

Agency: _______________________________________ Date: ________________________

 

Amount of remaining LIHEAP Crisis/Emergency Funds $_______________________

 

Estimated Rate of Expenditure per Day $_______________________

 

Amount of Contingency Funds Requested $_______________________

 

 

 

__________________________________________________

Authorized Signature/Date

 

______________________________________________________________________________

For KACA Use Only:

 

Amount Approved: $_______________________

 

 

 

__________________________________________________

Authorized Signature/Date

 

  

Revised 9/29/99

Community Action Energy Assistance Application

LIHEAP

1. Date ___/___/___ 2. Agency Code _______ 4. Program: KACA

(This application will be 3. County Code _______ S = Subsidy 1-800-456-3452 denied 5 days from this date if not completed) C = Crisis

A = Other CFC Ombudsman

1-800-372-2973

5. Head of Household Name: __________________________________ __________________________________ ______

(Last) (First) (M.I.)

6. ___________________________________________ 7. _____________________________________ KY ____________

(Street address) (City) (Zip Code)

8. ___________ - ___________________________ 9. Status:

(Area Code) (Telephone Number) A = Approved

D = Denied

u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u u

10. Name Relationship SS# Date of Birth Monthly Income Source

Head of Household Self ______________ ______________ ______________ _______

____________________________ ___________ ______________ ______________ ______________ _______

____________________________ ___________ ______________ ______________ ______________ _______

____________________________ ___________ ______________ ______________ ______________ _______

____________________________ ___________ ______________ ______________ ______________ _______

____________________________ ___________ ______________ ______________ ______________ _______

____________________________ ___________ ______________ ______________ ______________ _______

____________________________ ___________ ______________ ______________ ______________ _______

  1. Primary Heat Source _______ 13. Household Size _______ 15. Primary Source of Income _______ 16. Total Household
  2. Heat Source Paid _______ 14. Household Composition 1) Wages, Earned 2) SSI Monthly Income

1) Electric 2) Natural Gas (4 ) All that Apply 3) SS 4) K-TAP $_____________

3) Coal 4) Wood Age 60 + _____ 5) Child Support 6) Other

5) Propane 6) Fuel Oil, Age 2 and under _____ 7) No Income

Kerosene Ages 3, 4, 5 _____ 17. Verified by: _________________________________

Disability _____

18. Income Range ______ 19. Housing Type _______ 20. Energy Subsidy _______

1) 0-27% 2) 28-55% 1) Own 2) Rent/Subsidized Y = Yes

3) 56-83% 4) 84-110% 3) Rent/Non-Subsidized N = No 21. Liquid Resources: $___________

5) Over Income 4) Other

  1. I certify that the information on this application is correct and that I have been notified of my appeal rights. I understand that the receipt of assistance from this program through misrepresentation is punishable by fine or imprisonment. I give my permission to allow the agency or its funding source to verify the provided information with the source of my income or my heat provider as needed. I also give permission for the agency or its funding sources to provide information as required to the heat source. I agree to accept Weatherization services as available to reduce my home heating costs.

___________I certify I will be without heat within 4 days (all bulk fuels)

___________I certify that I have received a past due/disconnect notice (natural gas, electric)

_______________________________________________________________________ _______________________

(Applicant Signature) (Date of Signature)

Application
  1. Date - Enter the date that the application was started.
  2. Agency Code – Enter the two-digit code available in the appendix.
  3. County Code - Enter the 3-digit code, available in the appendix, for the applicant’s county of residence.
  4. Program - Enter S for Subsidy or C for Crisis or A for Other.
  5. Head of Household Name - Enter the name of the head of the household.
  6. Street or RR - Enter the street address or rural route address for the household.
  7. City/Zip- Enter the household’s city and zip code.
  8. Telephone Number - A number for the household or where a message may be left.
  9. Status – Enter A for Approved or D for Denied.
  10. Household Members - Enter the name, relationship to the head of household, social security number (if available), date of birth, monthly income and source of income for each household member. Please note that the first line is

designated for the head of the household. All other information for the head of household MUST be completed and there MUST be a social security number for the head of household.
  1. Primary Heat Source – Enter the one-digit code from item 12.
  2. Heat Source Paid – Enter the one-digit code.
  3. Household Size - Enter the number of people residing in the household at the time of application.
  4. Household Composition - Check (√) each line for the target group as listed on the application. To be counted as disabled, a household MUST meet the definition in DOE 440.3. Check each line for all the categories that apply.
  5. Primary Source of Income - Enter the one-digit code, only one, for the Primary source of income for the household. Note all codes are on the form.
  6. Total Household Monthly Income - Enter the dollar amount, rounded to the nearest dollar, of the total monthly income for all household members.
  7. Verified By - Enter the source that is used to verify household income. Codes may be used as determined by your supervisor, such as PO for "Print-Out", etc.
  8. Income Range – Enter the one digit code referring to the Percent of Poverty Chart in the appendix.
  9. Housing Type - Enter the one-digit code.
  10. Energy Subsidy – Crisis only, enter whether the household received assistance in Subsidy.
  11. Liquid Resources - Enter the amount of liquid resources for the household. Verification may be required if there is reason to doubt the consumer’s self-declaration.
  12. Signature of Applicant - Applications must be signed upon completion. Request the consumer to read or read to them the information contained in the signature block. Each household must be informed of its right to confidentiality and to appeal ANY case decision, including approvals. The secondary certification is to be checked as appropriate in the Crisis component.
  13. Subsidy Program – Enter benefit amount from the Benefit Matrix.
  14. Crisis Program – Enter amounts and time frames following the formula.
  15. Vendor(s) – Enter Vendor name(s) and Voucher #(s).
  16. Denial Code - If denied, enter the one-digit denial code.
  17. Void Date – Date application is voided if the household does not use voucher.
  18. CAA Info - To be used for local agency purpose AND to list referrals made or accepted AND presenting problems.
  19. Signature of Worker - Signature of the worker who completed the application and determined the benefit amount.

When possible, denied applications should have monthly income and income range completed.

 

 

 

 

Revised 9/29/99

_____________________________APPLICANT LOG (OPTIONAL)

DATE: __________________

COUNTY: __________________

APPLICANT LOG (OPTIONAL)

 

The Applicant Log may be used to log all applicants, to assist with crowd control, verify application date, record appointments and provide information to the Department of Community Based Services.

A new log will be started daily. You should complete the following information: date, have the consumer sign the log (if a staff person enters the consumer name, the consumer should initial or place his/her mark beside the written name), list the social security number for the head of household, address and phone number, and appointment time as applicable. At the end of the business day, after all consumers have been seen, you will need to note in the column "Eligible" a "Y" if the application was approved for benefits or a "N" if the application was denied. This will be done at the end of the day in order to obtain confidentiality of whether a consumer was assisted or not.

It is the intent of both the DCBS and KACA to provide recommended procedures for the Applicant Logs that will facilitate use of the information in a manner that will decrease the need for on-going request for information by the Food Stamp offices to provide consumers with the Standard Utility Allowance for agencies taking applications on paper.

Each CAA will be given the name of a contact person in each county DCBS office. The CAA staff person will be asked to make arrangements that are mutually satisfactory for providing the DCBS office with the Applicant Logs.

The recommended procedure for the CAA to record consumer information, for those consumers that sign the log on one date, but for various reasons, do not complete and have a case decision made is as follows:

Local agency variations to this form are allowed, provided the needed information is obtained to verify the applicant's initiation of the application process and as required for the Food Stamp Program.

 

Revised 9/29/99

How to complete the applicant log:

  1. Date - The date that applications are being taken.
  2. County - List county name or county code.
  3. Number - The order in which consumers sign the log.
  4. Consumer Name/Address - The name and complete address of the head of household.
  5. Social Security # - The social security number for the head of the household.
  6. Phone/Message # - The telephone number, or message number, where the consumer can be contacted.
  7. Signature of Head of Household or Authorized Representative - Signature of the head of household or representative that signifies that the application process has been started.
  8. Appt., Date/Time - Used if an appointment needs to be made.
  9. Eligible, Y or N - (completed at the end of work-day) Signifies whether the consumer is eligible for the program.
  10. Page - Designated page for the number of pages for that particular day.

 

  

 

DCBS VERIFICATION REQUEST

 

Date Submitted:________________________ Date Returned: _____________________