Save Print Reset

Agency Use Only

Missouri Department of Social Services

Application for Financial Help to Heat or Cool Your Home Date Stamp
FAMILY SUPPORT DIVISION

Low Income Home Energy Assistance Program (LIHEAP)

How to apply for LIHEAP
1. Fill out the application below. For each section, read the instructions carefully, answer every question, and gather the
required documents (extra papers) you need to turn in with your application. If your application is not complete, it
could be delayed or turned down.
2. Send your completed application and extra papers to the LIHEAP agency that processes applications in the county you
live in. See “Where to Mail Your LIHEAP Application”. This is found on the last page of this application.
When to apply for LIHEAP
• Send your application to arrive October 1st or after if: Any member of your household is age 60 or over, or if any
household member is disabled. You may need to send extra papers with your application to show that your household
has someone age 60 or over, or who is disabled.
• Send your application to arrive November 1st or after if: Your household doesn’t include a person age 60 or over, or
who is disabled.
After you send your application
The LIHEAP agency will review your application and extra papers you provided:
• If your application is not considered a crisis, we’ll review it within 30 working days after we receive it.
• We’ll send you a letter by mail that tells if you qualify for LIHEAP and the amount you’ll get. The amount you are
approved for may be reduced if you owe the Missouri Department of Social Services, Family Support Division LIHEAP
any overpayments from previous years.
Important:
• Even after you apply for Energy Assistance, continue to pay your heating bill so you don’t get disconnected or run out
of bulk fuel such as propane, wood, or pre-paid electric.
• When you pay your heating or cooling bill, send it to the utility company that sent you the bill, not to the LIHEAP
agency. LIHEAP agencies will only process your application. They will never accept utility payments, fees, or co-
payments.

Part 1 – Contact Information/Address Corrections

Fill in your current home address or make any necessary corrections if the home address on the application is not current.
Also, if possible, please list a phone or message number so we can contact you if we have questions. This will help avoid
delays as we review your application. USE BLUE OR BLACK INK.
Name

Home Address City State Zip Code

Mailing Address (If different from home address) City State Zip Code

County of Residence Email Phone Number Cell Number

Part 2 – Household Members

List every person living in your household, starting with yourself. Fill in each box for every household member. If there are
more than 10 people living in your home, list the others on a separate sheet of paper. Must include all nine numbers of the
social security number and the month, day, and year of the birth date(s) for all household members.
MO 886-4576 (8-18) Page 1 of 5
Part 2 – Household Members (continued)
Food Social U.S.
Sex Birth Disabled? Relationship
Name Stamps? Security Race Citizen?
M/F Date Yes/No to You
Yes/No Number Yes/No
SELF

Part 3 – Utility/Household Information

• All applicants: Fill in this section and send a copy of your most recent fuel statement and/or utility bill for both your
primary (main) heat source and your secondary (other) heat source.
• Applicants whose heat has been disconnected or may be disconnected soon:
• Send a copy of your disconnection notice along with the fuel statement or utility bill mentioned above, and
• If you or someone in your household suffers from a life threatening medical condition, send a medical statement from
a qualified doctor or nurse. The statement should say that the person has a life-threatening medical condition, but
does not have to state a diagnosis or condition.

Do you own your home or are you buying your home? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes   No
Has your home been weatherized by the local agency weatherization program? . . . . . . . . . . . . . . . . . . . . . . . Yes   No
Is your home all electric? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes   No
Do you or a household member suffer from a life-threatening medical condition? . . . . . . . . . . . . . . . . . . . . . . Yes   No

The type of furnace, wood stove, or heaters installed in your home determine what type of energy heats your home. For
example, if you have a natural gas furnace, your primary (main) heat source would be natural gas. Your secondary (other)
heat source would be electric because it’s used to run the furnace blower.
If your home is not all electric and your primary (main) energy supplier is Natural Gas or Tank Propane, you are required to
provide information about your electric supplier in the secondary (other) fields located below.

What primary (main) form of energy heats your home?

Natural Gas    Tank Propane    Electric Wood Cylinder Propane    Fuel Oil    Kerosene
Are you currently without a primary (main) heat source, because it got disconnected or you’re out of fuel? Yes   No
Are you currently in threat of not having a primary (main) heat source, because it may be disconnected soon or you’re low
on fuel?   Yes    No
If you answered yes to either question, please fill in the disconnection date or how much wood, propane, or pre-paid
electric you have:

List your main heat supplier’s name City

Whose name appears on the account? Account Number

MO 886-4576 (8-18) Page 2 of 5

 What secondary (other) form of energy heats your home? (Required to provide your electric supplier if your PRIMARY
(MAIN) supplier is Natural Gas or Tank Propane)
Natural Gas    Tank Propane    Electric Wood Cylinder Propane    Fuel Oil    Kerosene
Are you currently without a secondary (other) heat source, because it got disconnected or you’re out of fuel? Yes   No
Are you currently in threat of not having a secondary (other) heat source, because it may be disconnected soon or you’re low on
fuel?   Yes    No
If you answered yes to either question, please fill in the disconnection date or how much wood, propane, or pre-paid
electric you have:

List your secondary supplier’s name City

Whose name appears on the account? Account Number

Part 4 – If You Don’t Pay the Utility Company Directly

Fill in this section if you don’t pay your heating or cooling bill directly to the utility company.

The account is in my Landlord’s name and I pay my Landlord for my heating. Yes   No
I live in subsidized housing or receive Section 8. Yes   No
Heating costs are included in my rent. Yes   No
Cooling costs are included in my rent. Yes   No

Landlord’s Name Phone Number

Landlord’s Address

Part 5 – Income You Earn or Pay For Child Support

If anyone in your household has income from a job or self-employment:
• Fill in this section to show all income anyone gets from tips, payments for service, and wages for all jobs, even if someone
has more than one job, and
• Send copies of papers that show all gross income received by anyone last month, such as paystubs. Gross income is
income received before taxes are withheld. If anyone was employed in the last six (6) months, but did not receive income
from that job last month, we may need proof of final wages earned and last date worked from that employer.
List everyone in your home age 18 or older who received income from a job last month. (Include all jobs.)

Name Employer How Often Paid? Gross Pay Still Employed?

$
$
$
$

Did anyone in the household get income from self-employment last month? Yes   No
If yes, send a copy of the most recent Federal Income Tax Form 1040 for each self-employed person along with your
application.
MO 886-4576 (8-18) Page 3 of 5
Court-ordered Child Support that is paid to someone outside your household can be deducted so that it doesn’t count as
income. To receive this deduction, fill in your 8-digit Child Support case number below.

Did anyone pay court-ordered Child Support last month to someone outside of your household? Yes   No

If yes, how much? Name of person who pays the Child Support
$
List the 8-digit Child Support Case Number

Part 6 – Income That Isn’t Earned

If anyone in your household receives income that does not come from a job or self-employment:
• Fill in this section, and
• Send copies of papers that show all unearned income anyone received last month.

AMOUNT HOW OFTEN

SOURCES OF INCOME WHO RECEIvES THIS INCOME?
RECEIvED RECEIvED?
Social Security $
Supplemental Security Income (SSI) $
Temporary Assistance for Needy
Families (TANF)
$
Supplemental Aid to the Blind (SAB) $
Blind Pension (BP) $
Supplemental State Payments (SSP) $
Foster Care $
Alimony $
Child Support
List 8-Digit Case Number: __________
$

Unemployment Compensation $
Veterans Benefits $
Pensions $
Railroad Retirement $
Rent Received from Land or Buildings $
Money Received from Friends, Family,
or Organizations
$
Armed Forces Allotment $
Union Funds or Strike Benefits $
Worker’s Compensation or Temporary
Private Disability
$

Other Unearned Income

Specify: ________________________
$
MO 886-4576 (8-18) Page 4 of 5
Part 7 – Savings and Other Accounts
If anyone in your household has savings or other accounts, fill in the total amounts of money everyone has in each type of
account.

Type How Much? Type How Much?

Checking: Single and/or Joint Accounts $ Stocks/Bonds and Mutual Funds $

Savings: Single and/or Joint Accounts $ IRA/KEOGH and/or Deferred Compensation
$
Plans
CDs, Annuities, and/or Money Markets $

Part 8 – Notice That You Can Get a Fair Hearing – For informational purposes only
As an applicant for the Low Income Home Energy Assistance Program (LIHEAP), you may request a hearing for the
following reasons:
1) If your LIHEAP application is denied.
2) If your LIHEAP application is not reviewed timely.
A request for a hearing can be made in writing, by phone, by fax, or in-person.

Papers you must send with your application to avoid processing delays (send copies, not originals):
Application that is completely filled in, signed, and dated.
Proof of Social Security Number for everyone in the household. (Such as social security card, award letter, W-2)
Copies of utility and/or fuel bills for your primary (main) and secondary (other) fuel sources, including any
disconnection notices. The person listed on the fuel bill must be a member of the household who is age 18 or older.
Papers you need to send if any member of your household got any income last month:
Proof of all income (both earned and unearned) from last month for all household members who got it. Household
members who are active food stamp recipients do not need to provide proof of these incomes.
Copies of the most recent Federal Income Tax Form 1040 for any household members who earned money from self-
employment last month.

Part 9 – Your Consent for the LIHEAP Agency to Process (Review) This Application
Read the Consent for Processing in the box below and sign in blue or black ink. If you do not sign and date the application
in ink, your LIHEAP application will not be processed.

I hereby apply for assistance under the LIHEAP laws of the State of Missouri administered by the Department of Social
Services (DSS). I declare that the information I have given is true, correct, and complete to the best of my knowledge. I
realize that the information which I have given on this application will need to be verified by the LIHEAP agency.

If any household member declared on my application is currently receiving Food Stamps, TANF, or Child Support, I hereby
authorize the LIHEAP agency to use my Family Support Division (FSD) file to see if we qualify for LIHEAP. I hereby authorize
the LIHEAP agency and FSD to release information relating to my application for LIHEAP to my fuel supplier to determine if
I am eligible. I give permission to DSS to use information provided on this form for purposes of research, evaluation, and
analysis of the program.

I understand that I may be fined, imprisoned, or both under state or federal law if I make false statements on this
application in order to get benefits I am not entitled to receive.

Signature (Must sign in blue or black ink) Date

MO 886-4576 (8-18) Page 5 of 5

 WHERE TO MAIL YOUR LIHEAP APPLICATION
Search for your local office by referring to the county in which you live.

Audrain, Boone, Callaway, Cole, Cooper, Howard,

Moniteau, Osage Jefferson, Franklin
Central Missouri Community Action (CMCA) Jefferson-Franklin Community Action Corporation (JFCAC)
800 N Providence Rd Ste 103 PO Box 920
Columbia, MO 65203-4300 Hillsboro, MO 63050-0920
Phone number: (573) 443-1100 Phone number: (636) 789-2686

St. Louis County Camden, Crawford, Gasconade, Laclede, Maries, Miller,

Community Action Agency of St. Louis County (CAASTLC) Phelps, Pulaski
2709 Woodson Rd Missouri Ozarks Community Action, Inc. (MOCA)
Overland, MO 63114-4817 PO Box 69
Phone number: (314) 446-4420 Richland, MO 65556-0069
Phone number: (573) 765-3263
Andrew, Buchanan, Clinton, DeKalb
Community Action Partnership of Greater St. Joseph Carroll, Chariton, Johnson, Lafayette, Pettis, Ray, Saline
(CAPSTJOE) Missouri Valley Community Action Agency (MVCAA)
817 Monterey 1415 S Odell Ave
St. Joseph, MO 64503-3611 Marshall, MO 65340-3144
Phone number: (816) 233-8281 Phone number: (660) 886-7476

Lewis, Lincoln, Macon, Marion, Monroe, Montgomery,

Atchison, Gentry, Holt, Nodaway, Worth Pike, Ralls, Randolph, Shelby, St. Charles, Warren
Community Services, Inc. of Northwest Missouri (CSI) North East Community Action Corporation (NECAC)
PO Box 328 805 Business Highway 61 N
Maryville, MO 64468-0328 Bowling Green, MO 63334-1351
Phone number: (660) 582-3113 Phone number: (573) 324-0120

Adair, Clark, Knox, Schuyler, Scotland

Barton, Jasper, Newton, McDonald Community Action Partnership North East Missouri
Economic Security Corporation of Southwest Area (ESC) (CAPNEMO)
PO Box 207 PO Box 966
Joplin, MO 64802-0207 Kirksville, MO 63501-0966
Phone number: (417) 781-0352 Phone number: (660) 665-9855

Bollinger, Cape Girardeau, Iron, Madison, Perry, St. Douglas, Howell, Oregon, Ozark, Texas, Wright
Francois, Ste. Genevieve, Washington Ozark Action, Inc. (OAI)
East Missouri Action Agency (EMAA) 710 E Main St
PO Box 308 West Plains, MO 65775-3307
Park Hills, MO 63601-0308 Phone number: (417) 256-6147
Phone number: (800) 392-8663
Barry, Christian, Dade, Dallas, Greene, Lawrence, Polk,
Dunklin, Mississippi, New Madrid, Pemiscot, Scott, Stone, Taney, Webster
Stoddard Ozarks Area Community Action Corporation (OACAC)
Delta Area Economic Opportunity Corporation (DAEOC) 215 S Barnes Ave
99 Skyview Rd Springfield, MO 65802-2204
Portageville, MO 63873-9180 Phone number: (417) 864-3460
Phone number: (573) 379-3851
Butler, Carter, Dent, Reynolds, Ripley, Shannon, Wayne
South Central Missouri Community Action Agency (SCMCAA)
Caldwell, Daviess, Grundy, Harrison, Linn, Livingston, PO Box 6
Mercer, Putnam, Sullivan Winona, MO 65588-0006
Community Action Partnership North Central Missouri Phone number: (800) 325-4633
(CAPNCM)
1506 Oklahoma Ave Jackson, Clay, Platte
Trenton, MO 64683-2587 Mid America Assistance Coalition (MAAC)
Phone number: (660) 359-3907 4001 Blue Parkway, Suite 270
Kansas City, MO 64130-2350
City of St. Louis, Wellston Phone number: (816) 768-8900
Urban League (ULSTL)
3701 Grandel Square Bates, Benton, Cass, Cedar, Henry, Hickory, Morgan, St.
St. Louis, MO 63108-3627 Clair, Vernon
Phone number: (314) 615-3632 West Central Missouri Community Action Agency (WCMCAA)
106 W 4th Street
Appleton City, MO 64724-1402
Phone number (660) 476-2185