CERTIFICATE OF FINANCIAL NEED (CFN)

CERTIFICATE OF FINANCIAL NEED (CFN)

Indicate by check mark whether the applicant is applying for the 30-day extension or the hardship reconnection.

Name - Enter the Consumer’s name.

Social Security Number - Enter the Consumer’s Social Security Number.

Customer Name if Different from Applicant - Enter the name that the utilities are in, if different from the applicant listed in #1.

Address - Enter the Consumer’s address.

Utility Company - Enter the name of the Utility Company.

Address - Enter the address of the Utility Company.

Account Number - Enter the Customer’s Account Number, if available.

Services Disconnected - Enter the date service was disconnected (Reconnect only).

Certification Statement - Enter the total gross monthly income for the household and the number of persons in the household. The customer must sign and date when the statement is completed.

The Person Listed in #1 Above Is: - Determine if financial need exist by using the 130% poverty chart, printed on the form, and check the appropriate box.

Phone Contact Was Made - If phone contact is made with the utility company provider certifying financial need, enter the date of the contact.

The CAA Representative who completed the form must sign, enter the CAA address, phone number, and date the form. For Hardship Reconnection, make sure the consumer understands the provisions of reconnection as listed on the bottom of the form.

For all persons who apply for 30-day Extension of Service and/or Hardship Reconnection of Service, a county file is established and records maintained for three (3) years or, if audited, until the audit is completed.

1. For 30-day Extension of Service, complete in duplicate and distribute:

Original to consumer (or mailed directly to utility provider)

Copy to county file

2. For Hardship Reconnection of Service, complete in duplicate and distribute:

Original to consumer to take to the utility provider (this copy can be mailed to the provider upon the consumer’s request)

Copy to county file

Space Heater Loan Agreement
(Prior to loaning a kerosene heater, the fact sheet should be read to the consumer and

the Space Heater Loan Agreement signed by the Consumer and the CAA Representative.)

I,
Name and Address



have been informed on this date of the health and safety hazards related to the use of
Space heaters in my dwelling. I understand that this space heater is on loan from

Agency

and should only be used during this emergency situation, until fuel is restored or
my heat system is operable.

I also understand that I am expected to return or have the space heater picked up
not later than June 1 or when heat is restored to my home, whichever comes
first.





Consumer Signature						Date


Agency Representative						Date

Space Heater Loan Agreement

This form must be read to all applicants receiving a space heater. The applicant must sign this Agreement in order to receive a space heater. In addition, the Kerosene Space Heater Fact Sheet must be read and given to the applicant when receiving a kerosene space heater. On the previous page is an example of the Space Heater Loan Agreement.

Facts You Should Know About Using A Kerosene Space Heater

The kerosene heater you are receiving is on loan to you to provide heat in your home on a temporary basis until your permanent heat system can be restored. This space heater is not meant to replace your permanent heat system but only used during this emergency.

The only type fuel which can be used in this space heater is K-1 Kerosene. Misuse of this space heater may result in fire, explosion, health hazards to household members and moisture to your home. Extreme cautions should be taken in using this heater.

The following cautions will assist you in operating and maintaining your space heater safely and efficiently.

Use only K-1 Kerosene as a fuel, never gasoline or non-kerosene fuels.

Remember the unit is extremely hot while in operation. Do not touch top or front area during operation. Keep children, pets, clothing, furniture and other combustible objects at least three feet away from top and front area.

Make sure there is adequate ventilation. When burned, kerosene space heaters put carbon monoxide in the air which has no color, taste, or odor. Too much carbon monoxide in the home causes headaches, nausea, tiredness, confusion, dizziness and sometimes coma or death.

Burning kerosene space heaters also put large amounts of moisture in the air. This moisture changes into water on ceilings, walls and windows and can cause damage to the home over a period of time.

Placing the kerosene heater near a window opened one or two inches or opening an outside door one inch while being burned will help remove the carbon monoxide and moisture from the home.

This Kerosene heater should not be used in a bathroom or any other small room with the door closed.

Never leave the heater operating if you intend to leave for any period of time. Always make sure to turn the heater off and inspect to insure that it is completely extinguished prior to going to bed.

In addition to the above cautions, follow the manufacture’s instructions when operating this kerosene space heater. If manufacture’s instructions were not provided to you when you received our kerosene heater, please contact your local community action agency for instructions for the kerosene heater your received.

BOARD STATEMENT OF VENDOR SELECTION APPROVAL

By signature below, I do hereby certify that the Board of Directors of the _________________________, in an open meeting, on _____________, consistent with the requirements of KRS 61.805 through KRS 61.850, did review, and approve the written procedures and processes developed by the agency for the procurement of goods and services related to the LIHEAP activities and delegated to this agency by the Kentucky Association for Community Action, Inc.

I further certify that the Board of Directors did also concur with the implementation of these procedures and that I have been duly authorized by the Board to certify this information.


Signature/Title		Date

VENDOR DISCLOSURE STATEMENT

This form is to be completed by every member of the Board of Directors, every member of the Agency’s Executive Staff, and each LIHEAP staff person, prior to the solicitation of any vendor for the program. It is the responsibility of each Executive Director to obtain these Disclosure Statements and have them available for review.

By signature below, I hereby certify that any ownership or interest that I, or any member of my immediate family has in any business, partnership, or corporation that sells or provides fuel in any manner that may be used for home heating, within the State of Kentucky, is listed and disclosed on this form.

I also certify that I have been provided a copy of the code of conduct and conflict of interest standards.


Signature		Date

The businesses, partnerships, or corporations that I have interest in that meets the above mentioned criteria are:

Home Energy Assistance Program

Approved Vendor List (Optional in lieu of computer printout)

Agency

Date

FUEL TYPE

(Mark One)

Coal

Wood

Kerosene

Propane

Fuel Oil

Company Name

Counties Served

Address

City

State

Zip

Phone Number

SUBSIDY

CRISIS

(Mark One)

Bid

Sole Source

Consumer Select

(Mark One)

Bid

Sole Source

FUEL TYPE

(Mark One)

Coal

Wood

Kerosene

Propane

Fuel Oil

Company Name

Counties Served

Address

City

State

Zip

Phone Number

SUBSIDY

CRISIS

(Mark One)

Bid

Sole Source

Consumer Select

(Mark One)

Bid

Sole Source

FUEL TYPE

(Mark One)

Coal

Wood

Kerosene

Propane

Fuel Oil

Company Name

Counties Served

Address

City

State

Zip

Phone Number

SUBSIDY

CRISIS

(Mark One)

Bid

Sole Source

Consumer Select

(Mark One)

Bid

Sole Source

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP)

Vendor Agreement

Program Description

The Home Energy Assistance Program has two components, Subsidy and Crisis.

The Subsidy component provides benefits in the form of fuel or payment toward a utility bill for all households that are income eligible and that are responsible for home energy cost either directly or as an undesignated portion of their rent.

The Crisis component requires that eligible households also meet the Crisis definition:

the household is without heat if coal, wood or kerosene is the heat source; or

the household is within 4 days of running out of fuel if propane or fuel oil is the heat source; or

the household has received a past due or disconnect notice if natural gas or electric is the heat source; or

the household requires a heating system repair to obtain adequate heat; or

the household’s home heating costs are included as an undesignated portion of the rent, and the household has received an eviction notice for non-payment of rent; or
Emergency programs may be authorized during the summer.

Each vendor needs to be aware of and understand these basic program requirements before signing this agreement.

For bulk fuels, I understand that I have the consumers signature, certifying the delivery of the fuel, to receive payment.

Vendor Responsibilities

As a vendor for this program, I understand and agree to comply with the non-discrimination provisions which requires that I

Charge the LIHEAP household, in the normal billing process, the difference between the actual cost of home energy and the amount of the payment approved from the program;

Not treat households adversely because of the receipt of LIHEAP benefits;

Not discriminate, either in the cost of the goods supplied or the services provided against the eligible household for whom payment is being made;

Reconnect utilities and/or deliver fuel upon certification of payment; and

Not increase the household’s rent on the basis of the receipt of the payment.

I further agree to

Allow agency and/or other authorized officials to inspect records upon request;

Maintain records of financial transactions regarding LIHEAP for a period of three (3) years;

Provide information to the agency on any instances where I may be aware that a household has been approved for benefits by misrepresentation of the household’s situation;

Comply with the Equal Employment Opportunity standards;

Comply with the billing procedures established by the agency and included in this agreement as Attachment A; and

Provide fuel as specified and at the price quoted in the Application Bidding Form included in this agreement as Attachment B.


Vendor Signature Date

=================================================================================

_______________________________________________ _______________________

Business Name Telephone Number

_______________________________________________

Business Address

LIHEAP 99/00

Percent of Poverty Charts

Family Size: 1 Income Range Family Size: 6 Income Range

0-27% 0-$185 0-27% $0-$503

28-55% $186-$378 28-55% $504-$1,024

56-83% $379-$570 56-83% $1,025-$1,545

84-110% $571-$756 84-110% 1,546-$2,048

Family Size: 2 Income Range Family Size: 7 Income Range

0-27% 0-$249 0-27% $0-$566

28-55% $250-$507 28-55% $567-$1,153

56-83% $508-$765 56-83% $1,154-$1,741

84-110% $766-$1014 84-110% $1,742-$2,307

Family Size: 3 Income Range Family Size: 8 Income Range

0-27% 0-$312 0-27% $0-$630

28-55% $313-$636 28-55% $631-$1,283

56-83% $637-$960 56-83% $1,284-$1,936

84-110% $961-$1,273 84-110% $1,937-$2,565

Family Size: 4 Income Range Family Size: 9 Income Range

0-27% 0-$376 0-27% $0-$693

28-55% $377-$766 28-55% $694-$1,412

56-83% $767-$1,155 56-83% $1,413-$2,131

84-110% $1,156-$1,531 84-110% $2,132-$2,824

Family Size: 5 Income Range Family Size: 10 Income Range

0-27% 0-$439 0-27% $0-$757

28-55% $440-$895 28-55% $758-1,541

6-83% $896-$1,350 56-83% $1,542-$2,326

84-110% $1,351-$1,790 84-110% $2,327-$3,083

LIHEAP Agency Codes

Audubon Area Community Services
Bell-Whitley CSA
Big Sandy CAP
Blue Grass CAA
Central KY CAC
Daniel Boone Development Council
Gateway CSO
Harlan County CAA
KCEOC
Kentucky River Foothills
LKLP CAC
Lake Cumberland CSO
CAC - Lexington
Licking Valley CAP
Louisville-Jefferson County CAA
Middle KY River ADC
Multi-Purpose CAA
Northeast KY ADC
Northern KY CAC
Pennyrile Allied Community Services
Community Action Council of Southern KY
Tri-County CAA
West KY Allied Services

(Agency Codes must be two-digits.)

LIHEAP County Codes

001 Adair Lake Cumberland CAA 062 Larue Central KY CAA

002 Allen Southern KY CAA 063 Laurel Daniel Boone CAA

003 Anderson Blue Grass CAA 064 Lawrence Northeast KY CAA

004 Ballard West KY Allied CAA 065 Lee Middle KY River CAA

005 Barren Southern KY CAA 066 Leslie LKLP CAA

006 Bath Gateway CAA 067 Letcher LKLP CAA

007 Bell Bell-Whitley CAA 068 Lewis Licking Valley CAA

008 Boone Northern KY CAA 069 Lincoln Blue Grass CAA

009 Bourbon Community Action of Lexington 070 Livingston Pennyrile CAA

010 Boyd Northeast KY CAA 071 Logan Southern KY CAA

011 Boyle Blue Grass CAA 072 Lyon Pennyrile CAA

012 Bracken Licking Valley CAA 073 McCracken West KY Allied CAA

013 Breathitt Middle KY River CAA 074 McCreary Lake Cumberland CAA

014 Breckinridge Central KY CAA 075 McLean Audubon Area CAA

015 Bullitt Multi-Purpose CAA 076 Madison KY River Foothills CAA

016 Butler Southern KY CAA 077 Magoffin Big Sandy CAA

017 Caldwell Pennyrile CAA 078 Marion Central KY CAA

018 Calloway West KY Allied CAA 079 Marshall West KY Allied CAA

019 Campbell Northern KY CAA 080 Martin Big Sandy CAA

020 Carlisle West KY Allied CAA 081 Mason Licking Valley CAA

021 Carroll Northern KY CAA 082 Meade Central KY CAA

022 Carter Northeast KY CAA 083 Menifee Gateway CAA

023 Casey Lake Cumberland CAA 084 Mercer Blue Grass CAA

024 Christian Pennyrile CAA 085 Metcalfe Southern KY CAA

025 Clark KY River Foothills CAA 086 Monroe Southern KY CAA

026 Clay Daniel Boone CAA 087 Montgomery Gateway CAA

027 Clinton Lake Cumberland CAA 088 Morgan Gateway CAA

028 Crittenden Pennyrile CAA 089 Muhlenberg Pennyrile CAA

029 Cumberland Lake Cumberland CAA 090 Nelson Central KY CAA

030 Daviess Audubon CAA 091 Nicholas Community Action of Lexington

031 Edmonson Southern KY CAA 092 Ohio Audubon CAA

032 Elliott Northeast KY CAA 093 Oldham Tri-County CAA

033 Estill KY River Foothills CAA 094 Owen Northern KY CAA

034 Fayette Community Action of Lexington 095 Owsley Middle KY River CAA

035 Fleming Licking Valley CAA 096 Pendleton Northern KY CAA

036 Floyd Big Sandy CAA 097 Perry LKLP CAA

037 Franklin Blue Grass CAA 098 Pike Big Sandy CAA

038 Fulton West KY Allied CAA 099 Powell KY River Foothills CAA

039 Gallatin Northern KY CAA 100 Pulaski Lake Cumberland CAA

040 Garrard Blue Grass CAA 101 Robertson Licking Valley CAA

041 Grant Northern KY CAA 102 Rockcastle Daniel Boone CAA

042 Graves West KY Allied CAA 103 Rowan Gateway CAA

043 Grayson Central KY CAA 104 Russell Lake Cumberland CAA

044 Green Lake Cumberland CAA 105 Scott Blue Grass CAA

045 Greenup Northeast KY CAA 106 Shelby Multi-Purpose CAA

046 Hancock Audubon CAA 107 Simpson Southern KY CAA

047 Hardin Central KY CAA 108 Spencer Multi-Purpose CAA

048 Harlan Harlan CAA 109 Taylor Lake Cumberland CAA

049 Harrison Community Action of Lexington 110 Todd Pennyrile CAA

050 Hart Southern KY CAA 111 Trigg Pennyrile CAA

051 Henderson Audubon CAA 112 Trimble Tri-County CAA

052 Henry Tri-County CAA 113 Union Audubon CAA

053 Hickman West KY Allied CAA 114 Warren Southern KY CAA

054 Hopkins Pennyrile CAA 115 Washington Central KY CAA

055 Jackson Daniel Boone CAA 116 Wayne Lake Cumberland CAA

056 Jefferson Louisville-Jefferson CAA 117 Webster Audubon CAA

057 Jessamine Blue Grass CAA 118 Whitley Bell-Whitley CAA

058 Johnson Big Sandy CAA 119 Wolfe Middle KY River CAA

059 Kenton Northern KY CAA 120 Woodford Blue Grass CAA

060 Knott LKLP CAA

061 Knox KCEOC

County Codes Must be 3 Digit.
LIHEAP COMPONENT

PROGRAM CLOSING REPORT

(This form is required if funds are expended prior to 3/15)

Crisis: _______________

Other/Emergency: _______________

Agency Name: ______________________________________________

Last Date of Program: ______________________________________________

___________________________________ ____________________

Authorized Signature Date

__________________________________________________________________

Distribution:

CAA will fax to KACA.

KACA will fax to EAB and the Ombudsman's Office.

Frequently Used Toll-Free Numbers

KY Association for Community Action (KACA) 1-800-456-3452

CFC Ombudsman Office 1-800-372-2973

KY Housing Corporation 1-800-633-8896

Social Security 1-800-772-1213

Public Service Commission 1-800-772-4636

HUD Housing Discrimination 1-800-669-9777

BATCHING SCHEDULE

Paper Applications Agency Code Batch # Due Date

11-01-99 to 11-05-99 1 11-12-99

11-08-99 to 11-12-99 2 11-19-99

11-15-99 to 11-19-99 3 11-26-99

11-22-99 to 11-26-99 4 12-03-99

11-29-99 to 11-30-99 5 12-07-99

12-01-99 to 12-03-99 6 12-10-99

12-07-99 to 12-10-99 7 12-17-99

01-10-00 to 01-14-00 8 01-21-00

01-17-00 to 01-21-00 9 01-28-00

01-24-00 to 01-28-00 10 02-04-00

01-31-00 11 02-07-00

02-01-00 to 02-04-00 12 02-11-00

02-07-00 to 02-11-00 13 02-18-00

02-14-00 to 02-18-00 14 02-25-00

02-21-00 to 02-25-00 15 03-02-00

02-28-00 to 02-29-00 16 03-07-00

03-01-00 to 03-03-00 17 03-10-00

03-06-00 to 03-10-00 18 03-17-00

03-13-00 to 03-15-00 19 03-22-00

Disks

11-01-99 to 11-30-99 1 12-10-99

12-01-99 to 12-10-99 2 01-10-99

01-10-00 to 01-28-00 3 02-10-00

02-01-00 to 02-29-00 4 03-10-00

03-01-00 to 03-15-00 5 04-10-00

Downloads schedules will be developed with each agency using this procedure.

STATE-WIDE VENDOR TRACKING NUMBERS

0001 American Electric Power

0002 Columbia Gas

0003 Cynergy

0004 Delta Gas

0005 Kentucky Utilities

0006 Louisville Gas and Electric

0007 TN Valley

0008 West KY Gas

0009 Big River Electric Corp.

0010 Big Sandy RECC

0011 Blue Grass Energy Corp.

0012 Clark Energy Corp.

0013 Cumberland Valley Electric

0014 East KY Power Corp.

0015 Farmer RECC

0016 Fleming Mason Energy Corp.

0017 Grayson RECC

0018 Harrison County RECC

0019 Inter-County Energy Cooperative

0020 Jackson Energy Cooperative

0021 Jackson Purchase Energy Cooperative

0022 Kenergy Cooperative

0023 Licking Valley RECC

0024 Meade County RECC

0025 Molin RECC

0026 Owen Electric Cooperative

0027 Salt River Electric Cooperative

0028 Shelby Energy Cooperative

0029 Taylor County RECC

Low-Income

Home Energy Assistance Program

Compliance Review

1999-2000

Program Description:

The Kentucky Association for Community Action (KACA) has entered into a subcontract agreement with Community Action Agency for the operation of the Low-Income Home Energy Assistance Program (LIHEAP). The program regulations and procedures are outlined in your subcontract and the 1999-00 LIHEAP Manual. Each agency received copies of the manual at the KACA LIHEAP training.

1.) Agency name:

Date of Final Review:

Date of On-site visit(s):

4.) Subcontract Agreement #

5.) Contract Period: 08-01-99 to 06-30-00
INTERVIEW (ON-SITE)

6.) Agency Program Personnel:

6A.) Program Coordinator/Director:

% of time charged directly to the program:

% of annual time charged to the program:

Provided with a copy of the LIHEAP Manual?

6B.) Program Financial Manager/Director:
% of time charged directly to the program:

% of annual time charged to the program:

Provided with a copy of the LIHEAP Manual?

7.) Program Operation:

7A.) SUBSIDY COMPONENT

Start date 11-01-99
Date last application was taken

Total # of Subsidy applications taken

Total # of applications that were denied

7B.) CRISIS COMPONENT

Start date:

Date last application was taken
Total # of Crisis applications taken

Total # of Crisis applications denied

7C.) Emergency Component

Start date:

Date last application was taken
Total # of Emergency applications taken

Total # of Emergency applications denied

Describe outreach activities used to ensure that eligible households, especially

households with individuals who are homebound, are made aware of the program.

9.) List the dates and times that each county office in the service area is open.
10.) How does the agency provide for individuals who are homebound to apply without leaving home?
11.) Has the agency purchased space heaters, blankets and/or sleeping bags for loan? If so, how many? Did the agency follow the policy in the LIHEAP manual?

12.) Has the agency provided each applicant with a notification regarding the disposition of his case and the right to appeal?
13.) Does the agency provide each denied client written notification of reason for denial and the name, address and telephone number of agency staff to answer questions and receive appeal requests?
14.) Has the Executive Director and/or his designee reviewed a minimum of 2% of the cases and submitted summary reports (paper applications only)?
15.) Review Board minutes for Board review and approval of the procurement process. Dates for each Board meeting and copy of minutes.

16.) Review Fuel Vendor Disclosure statements. Are there signed copies for all required staff and Board members? If all forms are not complete, inquire about the process.
17.) Review and comment on vendor agreements and attachments. Are copies available for the vendors?
18.) Does the agency conduct on-site visits during Crisis when there is suspected fraud or a complaint? What is their procedure.
19.) Does the agency maintain a Complaint File? What is their procedure.

20.) List the total number of complaints by name and county. What was the resolution?

21.) For the Crisis component, review the fuel verification records. Comments.
22.) Has the agency submitted to KACA copies of all client related forms to be used in the program and listed the toll-free numbers for KACA and the Ombudsman?
23.) Has the agency participated in meetings and training as required by KACA?

24.) Has the agency issued Certificates of Financial Need and Hardship Reconnect forms in all counties? Numbers for each county.
25.) Has the agency developed a price analysis for the Crisis component?
26.) Has the agency listed any job openings created as a result of this agreement with the Employment Service?
27.) Did the agency request approval of the client energy conservation counseling and education component?

Are volunteers used to help operate the program? If so, how is training provided?

29.) Explain how the co-payment process works in your agency? Comments:

POLICY AND PROCEDURE REVIEW (ON-SITE)

30.) Does the agency have written procedures to address complaints and provide for hearings?

31.) Does the agency have a written confidentiality policy? Review and comment.

32.) Review vendor selection procedures used to procure goods and services to ensure that they meet the minimum requirements cited in the manual and supplements.
33.) Does the agency have a written policy consistent with KRS 45A.340 (conflicts of interest of public officers and employees)? Comments:

34.) Does the agency have a written policy consistent with KRS 45A.355 (gratuities and kickbacks - use of confidential information)? Comments:

35.) Review the agency’s policy regarding lobbying activities to ensure compliance with section 1352, Title 31, US Code. Comments:

36.) Does the agency have a written Fraud & Abuse policy?

Does the agency have a policy for crowd control, heavy days and last days of programs, and reporting to the local DCBS? What is their policy?

APPLICATION REVIEW (ON-SITE when applicable)
38a.) SUBSIDY: Total # of applications reviewed

RESULTS BASED ON REVIEW:

# of completed applications

Income documentation correct?

Comments - T/A provided:
38 b). CRISIS: Total # of applications reviewed

RESULTS BASED ON REVIEW:

# of applications completed

# of cut-off/ eviction notices

Income documentation correct?

Co-payment correct?

Comments - T/A provided:

38c.) Emergency: Total # of applications reviewed

RESULTS BASED ON REVIEW:

# of completed applications

Income documentation correct?

Comments - T/A provided:

Review "Batching" procedures. Are procedures in compliance with the manual?

FINANCIAL REVIEW (ON-SITE):
40.) Review the agency’s ledger to track if voucher payments are being recorded properly.
41.) Track when payments are received and when payments are made to the vendors. Are vendors paid within 3 days of receipt of funds from KACA? Comments:
42.) Does the agency have a system for review of vendor billing to assure that all vouchers paid have proper documentation?

43.) Has the agency earned interest on LIHEAP funds? If so, how has the interest been used?.
44.) Does the agency have a procedure for obtaining an audit of the LIHEAP program? Comments:

45.) Does the audit engagement letter contain the appropriate requirements and audit specifications?

How does the agency assure that all costs involved with the program are not charged to other programs?

How does the agency assure that LIHEAP funds are not used for the purchases, construction or permanent improvement of any building or facility?

Exit Interview

Do you have any suggestions as to how training and assistance to your agency can be improved?

Needed Follow-up.

50.) Monitoring staff: Agency

KACA

Other

Revised 09/99

NOTES