Low Income Home Energy Assistance Program 2020 (LIHEAP

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ARD

COUNTY

FLORIDA

Board of County Commissioners, Broward County, Florida

HUMAN SERVICES DEPARTMENT

FAMILY SUCCESS ADMINISTRATION DIVISION

COMMUNITY ACTION AGENCY (CAA)

Low Income Home Energy Assistance Program 2020

(LIHEAP) Criteria

FREE ELECTRIC ASSISTANCE

The Community Action Agency’s LIHEAP Program is able to assist

residents who meet the 150% Poverty Guidelines based on household size:

Household size 50% Annual Poverty Level 150%

1…………..…$6,380 …....…………...… $19,140

2………….….$8,620 ………………....... $25,860

3………..….$10,860 …………….……... $32,580

4……….…..$13,100 …………..……….. $39,300

5……….…..$15,340 …………..……….. $46,020

6……….…..$17,580 ………….….…….. $52,740

7……….…..$19,820 ……….…….…….. $59,460

8……….…..$22,060 ………..………….. $66,180

For each additional person, add $2,240 to 50% poverty level and $6,720 to 150% poverty level.

The above guidelines are subject to change, please contact the CAA main office for updates.

FOR ADDITIONAL INFORMATION CALL

MONDAY through FRIDAY 8:00 AM till 5:00 PM

CALL AHEAD FOR INFORMATION ON DATES AND TIMES

TO COMPLETE AND DROP OFF YOUR APPLICATION

AT ONE OF OUR CENTERS:

Edgar P. Mills Multi-Purpose Center

900 N.W. 31 Ave., Suite 3100

Fort Lauderdale, FL 33311

Phone: 954-357-5025

Fax: 954-357-5026

broward.org/FamilySuccess

Annie L. Weaver Health Center &

Family Success Center

2011 N.W. 3rd Ave.

Northwest Family

Success Center

10077 N.W. 29th St.

South Region Family Success

Center (Carver Ranches)

4733 S.W. 18th St.

Pompano Beach, FL 33060

(954) 357-5340

Coral Springs, FL 33065

(954) 357-5000

Hollywood, FL 33023

(954) 357-5650

CAA-LIHEAP-3 Revised 07/20/2020 Page 1 of 2 Reviewed 07/20/2020

WHEN APPLYING FOR ENERGY ASSISTANCE CLIENTS MUST

PROVIDE THEIR OWN COPIES OF THE FOLLOWING:

• Broward County Florida Picture Identification (Adult Members 18 & Older)

• Proof of Permanent Resident Status for all non U.S. citizens

• Social Security Cards For All Household Members

• Birth Certificate for Children Age 5 or Younger

• Current Section 8 or Public Housing Lease Contract

• If you receive Section 8 or Public Housing, bring a copy of your 50059 Form

which shows your current utility subsidy/allowance

• Other documentation may be required to explain management, if your current

income is insufficient to meet household expenses.

• If necessary, additional documents may be requested upon review of your

application in order to determine eligibility

• Valid FPL Bill

Proof of Income for All Household Members, for the past 30

days including, but not limited to:

• Current Year Disability and/or SSI Benefits Statement

• Current Year Senior Citizens: Retirement Benefits Statement

• Current Pay Stubs (consecutive pay stubs for last 30 days of employment)

• Company Letterhead verifying start date, pay rate, average hours worked per

week, frequency of pay, and day of week paid (Thursday’s, Friday’s, etc.)

• Current Unemployment Wage Determination Statement

• Current Pension Printout

• Current Child Support Verification Printout

• Current AFDC Verification Printouts

• Current Veteran Benefits

• Current Worker Compensation Benefits

CLIENTS MUST PROVIDE THEIR OWN COPIES

CAA-LIHEAP-3 Revised 07/20/2020 Page 2 of 2 Reviewed 07/20/2020

FLORIDA

_____________________________________ ___________________________

_____________________________________

Board of County Commissioners, Broward County, Florida

HUMAN SERVICES DEPARTMENT

FAMILY SUCCESS ADMINISTRATION DIVISION

BROWARD COUNTY COMMUNITY ACTION AGENCY

2020 LOW INCOME HOME ENERGY ASSISTANCE PROGRAM

(LIHEAP APPLICATION)

The Community Action Agency’s Low Income Home Energy Assistance Program (LIHEAP) is able to

assist Broward County residents with gross household incomes at or below 150% of the federal

poverty level.

Customer Responsibilities:

1. File an application with complete and correct information.

2. Provide valid picture identification for all adult household members, such as a current Broward

County driver’s license or identification card.

3. Verify income is at or below 150% of the poverty level.

4. Verify household size.

5. Provide other required documents, if necessary, to determine eligibility, such as proof of alien

status for all non-U.S. citizens, FPL bill, etc.

Community Action Agency Responsibilities:

1. Advocate for customer.

2. Assist financially where applicable.

YOU HAVE THE RIGHT TO AN APPEAL if you are not satisfied with the case decision that is made

within the Program’s guidelines.

1. You will be sent a written notice of the disposition of your application.

2. You may make an informal appeal to a supervisor.

3. You may make a verbal or written appeal to the Program Director.

Customer Signature Date

Customer Name (Print)

Customer Email Address

CAA-LIHEAP-1 Revised 07/20/2020 Page 1 of 4 Reviewed 07/20/2020

_________________________ _________________________________________________________ ________________

BROWARD COUNTY COMMUNITY ACTION AGENCY

2020

LIHEAP APPLICATION

CAA use

:

Date Stamp:

Remember to attach copies of the following:

__ Social Security cards for all household members

__ Proof of past 30 days income for all household members

__ Broward Picture ID for adult household members

__FPL (energy) bill

__ Birth certificates for children 5 or younger

__ Proof of disability

Dear Applicant:

( ) Home energy

( ) Crisis energy

( ) Disaster energy

Your LIHEAP application is not a commitment that your bill will be paid. If you qualify for the program while

funds remain available, a credit will be sent directly to your utility vendor, and you will be responsible to pay any

balance remaining after the credit is applied. Meanwhile, please keep paying as much of your bill as soon as you

can to avoid penalties such as disconnect/reconnect fees, additional deposits, interest, late charges, or having

your power shut off.

1. Please fill out the application completely. Provide information for yourself first, and then each person living in

your home. If more than 8 persons live in your home (or if you need to provide additional information), list the

additional persons giving the same information on a separate sheet of paper and attach to this form.

NAME (Please Print)

SS#

Date of Birth

Age

S

e

x

Relation

To

Applicant

Race

Last

Grade

Completed

Disabled

Y/N

Monthly

Income

Amount

SELF

Check type of Income received in household: __ Wages, __ self-employment, __ Social Security, __child support,

__unemployment, __ retirement benefits, __ SSI, __ TANF/WAGES, __ pension, __ other (please list ________________ )

2. Have you or any member of the household received LIHEAP or EHEAP assistance in the last 12 months? Yes ____ No ____

If “yes”, complete the following:

Name of agency providing help Type of help (LIHEAP Home Energy, Crisis, Disaster, or EHEAP Crisis) Date(s) received

CAA-LIHEAP-1 Revised 07/20/2020 Page 2 of 4 Reviewed 07/20/2020

_______________________________________________________________________________________

_____________________________ ____________________ ____________________

_______________________________________________________________________________________

3. If you are applying for LIHEAP crisis assistance, describe the crisis: _______________________________

4. If your monthly household income is less than 50% of the poverty level, and you do not receive food stamps,

explain how you pay for food, shelter, clothing, transportation, hygiene products, and home utilities. ________

5. Provide a telephone number where we can reach you: home: ( ) ____________________________

work: ( ) _______________________________ cell: ( ) ________________________________

6. Provide your living address including county:

Street Number and Name, RFD, Apt Number or Lot Number:

City or Town State Zip Code County

7. Provide your mailing address if different from above:

Street Number and Name, RFD, Apt Number or Lot Number:

City or Town State Zip Code County

8. Complete the following for your household: Number of elderly persons (60 or older): ____

Number of disabled: ____ (attach income documentation) Number of children, age 5 or younger: _____

9. Home Energy Company information: Please provide your FPL account number and FPL telephone number.

Home Energy Company or Landlord Account Number Telephone Number

10. If you share your living or mailing address with others who are not part of your home, list their names:

11. If you or anyone in your home is not a U.S. citizen or an alien lawfully admitted for permanent residence,

list the name and alien status under the Immigration and Naturalization Act below:

Name: ___________________________________________ Alien Status: __________________________

12. Are you or any member of your household a member of the Poarch Creek Indian Tribe? :

Yes __________ No __________

CAA-LIHEAP-1 Revised 07/20/2020 Page 3 of 4 Reviewed 07/20/2020

13. If you live in government subsidized housing, Section 8 housing, a dormitory, assisted living facility or adult foster

home, list the name of the place: ___________________________________________________

14. My Section 8 or Public Housing Utility Subsidy/Allowance is $ __________________ (attach documentation)

15. Check the following programs that anyone in your household is currently eligible for or receiving assistance from:

CSBG ____ Weatherization ____ TANF/WAGES ____ Food Stamps ____ None ____

16. Are you or anyone in your household related to any employee of this agency? Yes _____ No _____

If yes, Name of Employee ________________________________ Relationship _____________________

17. Attach a copy of the bill from your fuel/energy supplier.

"Under penalties of perjury, I hereby certify that the information I have given above is, to the best of my knowledge, true and complete. I do

understand that this is an application to receive federal money and that receiving federal monies by using false information may result in legal

consequences. I am also accepting responsibility for those consequences. I understand that priority will be given to applicant households with

members who are elderly, disabled or have children age 5 or younger. I authorize all persons and organizations named on this application to

supply information to the Agency. I further authorize the Agency to make benefit payments directly to my fuel supplier. I am aware that after I have

provided all the information requested, if I am applying for crisis assistance, the Agency has 18 hours to act upon my application. If I am applying

for Home Energy Assistance, the Agency has 15 working days to approve or deny my application. I am aware that upon approval the Agency has

45 days to make a payment to my fuel supplier on my behalf. I am also aware that if I am approved or denied within the time allowed or not

approved for the correct amount, I have a right to an appeal.

Applicant’s Signature: _____________________________________ Date: _________________________

(Note: If signed with an “X” two witnesses are required.)

Eligibility Worker’s Signature: _______________________________ Date: _________________________

I have determined the eligibility of the applicant. I am not the applicant, nor am I a friend, relative or employee of the applicant.

Supervisor / Edit Staff: ____________________________________ Date: _________________________

CAA use:

For households with elderly persons age 60 or older applying for crisis and/or disaster assistance, document

notification to EHEAP staff before making commitment to FPL.

Does the applicant own their own home? Yes ____ No ____. If the applicant is a homeowner that has been

approved for LIHEAP benefits, they may be referred to the local Weatherization Assistance Program.

Return application to:

Community Action Agency, 900 N.W. 31

st

Avenue, Suite 3100, Fort Lauderdale, FL 33311

Hours of Operation: Monday – Friday, 8:00 AM to 5:00 PM

CAA-LIHEAP-1 Revised 07/20/2020 Page 4 of 4 Reviewed 07/20/2020

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__________________________ _______________________________________

Board of County Commissioners, Broward County, Florida

HUMAN SERVICES DEPARTMENT

FAMILY SUCCESS ADMINISTRATION DIVISION

COMMUNITY ACTION AGENCY

NOTICE REGARDING COLLECTION OF SOCIAL SECURITY NUMBERS

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM

The following disclosure is being made pursuant to section 119.071(5), Florida Statutes.

Social security numbers of applicants and household members are requested because this information has been

determined to be imperative for the performance of the duties and responsibilities prescribed by law under the

Low Income Home Energy Assistance Program. This information is not required by state or federal law;

however, social security numbers are necessary to determine eligibility for program services and specifically for

the following purposes:

1. To verify an applicant’s identity.

2. To verify household size.

3. To verify household income.

A social security number collected pursuant to this notice can only be used by the Florida Department of

Economic Opportunity and the Broward County Community Action Agency (subgrantee) for the purposes

specified above.

Nondisclosure except under limited circumstances.

Social security numbers will not be disclosed to others unless required or authorized by Florida law. Section

119.071(5), Florida Statutes, allows disclosure of a person’s social security number under the following specific,

limited circumstances:

• If disclosure is expressly required by federal or Florida law or is necessary for the agency or

governmental entity to perform its duties and responsibilities;

• If the individual expressly consents to disclosure in writing;

• If disclosure is made to prevent and combat terrorism pursuant to the U.S. Patriot Act of 2001 or

Presidential Executive Order 13224 (blocking property and prohibiting business transactions with

persons who commit, threaten to commit, or support terrorism);

• For an agency employee and dependents, if disclosure is necessary to administer the person’s

health benefits or pension plan funds; or

• If disclosure is for the purpose of the administration of the Uniform Commercial Code by the office

of the Secretary of State.

• If disclosure is requested by a commercial entity for permissible uses under the federal Driver’s

Privacy Protection Act of 1994, the federal Fair Credit Reporting Act, or the federal Financial

Services Modernization Act of 1999 (for example, to verify the accuracy of personal information

provided by the individual to the commercial entity; use by an insurer in connection with claims

investigation or anti-fraud activities; for use in connection with a credit transaction).

Acknowledgment of Receipt of Notice

I confirm that I have been provided a copy of this Notice regarding the collection of my social security number

and the social security numbers of all household occupants as part of the application process for the Florida Low

Income Home Energy Assistance Program.

Date Applicant’s Signature

CAA-LIHEAP-2 Revised 04/01/2014 Page 1 of 1 Reviewed 04/01/2014

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Authorization for Release of General and/or Confidential Information

For LIHEAP/EHEAP Federal Reporting

The Florida Department of Economic Opportunity’s (DEO) Low Income Home Energy Assistance Program (LIHEAP)

Program Office is requesting that you authorize your utility service provider to disclose the following information to

the LIHEAP office to which you are applying for assistance:

• Your utility account status and history, such as payment history, past due amounts, deposits, current

shut-off due dates or disconnection, current life support status, payment arrangements, and history of

energy assistance payments.

• Your total annual energy usage and charges for up to twelve months.

The Florida LIHEAP office and its contractors will use this information to develop LIHEAP program performance

measures and meet Federal reporting requirements.

Please note that:

 You have a right to receive a copy of this form.

 You are not required to authorize your utility service provider to disclose your customer data.

 Your decision not to authorize the disclosure will not affect your utility services or any LIHEAP assistance

you may be eligible for.

 Your utility service provider may not disclose your customer data unless you authorize the disclosure to the

LIHEAP office, DEO, or as otherwise permitted or required by laws or regulations.

 Your utility service provider will have no control over the data disclosed pursuant to this consent, and will

not be responsible for monitoring or taking any steps to ensure that the Florida LIHEAP office maintains the

confidentiality of the data or uses the data as authorized by you.

 The Florida LIHEAP office will not disclose any private applicant information except for the purpose of

administering public assistance as defined by State and Federal laws and regulations and developing LIHEAP

program performance measures.

ACCOUNT HOLDER (CUSTOMER NAME):

SERVICE ADDRESS FOR UTILITY:

NAME OF UTILITY SERVICE PROVIDER:

UTILITY ACCOUNT NUMBER:

PHONE NUMBER FOR UTILITY ACCOUNT:

SECTION A: APPLICANT READS AND COMPLETES THIS SECTION ONLY IF HE/SHE IS THE ACCOUNT HOLDER

I hereby authorize the above named utility and this agency to disclose pertinent information regarding my

account to agencies that may provide me financial assistance, including the Florida LIHEAP Office. I understand

that the purpose of this disclosure is solely for federal reporting purposes and does not determine my eligibility

for assistance. I further understand that some of the information the above named utility may provide to this

agency may be considered confidential. I also understand that the above named utility does not and will not

have control over any account information provided to agencies pursuant to this Authorization, and I will hold

the utility harmless for any claim related to the account information provided. All information is accurate to the

best of my knowledge. The agency may verify information contained in the payment assistance application,

including the utility account for which I am seeking assistance.

!OUNT HOLDER’S SIGN!TURE: _____________________________________ D!TE: ________________

Effective Date: 10.1.15 (Ver. 1) Page 1

SECTION B: APPLICANT READS AND COMPLETES THIS SECTION ONLY IF HE/SHE IS NOT THE ACCOUNT HOLDER

As applicant for payment assistance for the above named utility account, I hereby confirm, under penalty of

perjury, that I am an Authorized Representative on behalf of the Account Holder and I have authority to initiate

this assistance application on his/her behalf. This may be confirmed at the agency’s discretion, by contacting the

Account Holder. I, and the Account Holder, understand that the purpose of this disclosure is solely for federal

reporting purposes and does not determine my eligibility. I further understand that some of the information the

above named utility may provide to this agency may be considered confidential. I also understand that the above

named utility does not and will not have control over any account information provided to agencies pursuant to

this Authorization, and I will hold the utility harmless for any claim related to the account information provided.

All information is accurate to the best of my knowledge. The agency may verify information contained in the

payment assistance application, including the utility account for which I am seeking assistance.

!PPLI!NT’S N!ME (NOT !OUNT HOLDER): ________________________________________________

!PPLI!NT’S PHONE NUMER: _____________________________________________________________

!PPLI!NT’S SIGN!TURE: __________________________________________ D!TE: _________________

SECTION C: FOR AGENCY USE ONLY

!gency must maintain this form in the !pplicant’s file and make it available to the utility vendor of record upon

request, for accounting and auditing purposes.

AGENCY NAME: _____ BROWARD COUNTY COMMUNITY ACTION AGENCY _________

PHONE: ______________954-357-5025_________________________________________

!GENY !SEWORKER’S N!ME: _______________________________________________

!GENY !SEWORKER’S SIGN!TURE: ___________________________________________

DATE: ______________________

Effective Date: 10.1.15 (Ver. 1) Page 2

Board of County Commissioners, Broward County, Florida

HUMAN SERVICES DEPARTMENT

FAMILY SUCCESS ADMINISTRATION DIVISION

Community Action Agency

Low Income Home Energy Assistance Program (LIHEAP)

Community Service Block Grant (CSBG)

LIHEAP to CSBG REFERRAL FORM

CAA use:

Client Name: ______________________________ PPL: __________ %

Social Security Number (Last 4): _______________ LIHEAP Case Worker: __________

1. Do you, or anyone in your household, have any interest in attending school or vocational

training to improve job skills? ___ yes ___ no

2. Do you believe financial assistance with tuition, books, and child care will make it easier to

attend school or training sessions? ___ yes ___ no

If you, or someone in your home, want help to reach educational and/or vocational goals, please

provide us with the name and contact number of the household member below (must be age 18

or older) so that someone on our CSBG team may call to discuss how we can help.

The household member seeking educational/vocational assistance is:

First Name: ________________________ Last Name: ________________________________

Primary phone number: __________________ Alternate phone number: __________________

CAA-3 Revised 04/23/2018 Page 1 of 1 Reviewed 04/23/2018