Follow the steps to successfully complete the LIHEAP Intake Form.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by entering your agency file number, the certified representative's name, the date, and the time of completion at the top of the form.
3. Fill in your last name, first name, and middle initial in the designated areas.
4. In the next section, provide the poverty level percentage and the LIHEAP amount along with any other assistance information.
5. Enter your street address and mailing address if they differ.
6. Provide your city, state, zip code, and county of residence, maintaining accurate and current information.
7. List your telephone and cell phone numbers along with your email address for communication purposes.
8. If applicable, include your VA number and complete the section that lists all household members, their relationship to the head of household, dates of birth, and sex.
9. Detail your sources of income along with the rate of pay, specifying the Total Income for both 3-month and 12-month periods.
10. Provide your social security number, ethnic background, health insurance details, disability status, education level, marital status, and veteran status.
11. Complete the heating and electric service sections, including the company name, account number, and name on the account.
12. Indicate the main source of heating by checking the appropriate box.
13. Identify your housing type by ticking the correct option.
14. Complete the housing status section by checking how you are currently housed.
15. Answer the questions regarding assistance and assets, including any potential disconnect notices.
16. Finally, certify the information provided is true and authorize the agency to share information as needed, then sign and date the form.
17. After completing all sections, ensure to save changes, download, print, or share the form as necessary.

Take the necessary steps to fill out your LIHEAP Intake Form online today.