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Home Energy Assistance Program (HEAP)

Directions

Directions for Completing the 1996-1997 Home Energy Assistance Program (Heap) Application

Complete the enclosed application and submit to The Department for the Aging {DFTA) ONLY if you are:

  • 60 years of age or older; or
  • Receive Supplemental Security Income (SSI) Code A and live alone or with a spouse only; or
  • Head of household receiving Social Security Disability Benefits.

IMPORTANT INFORMATION

Please read the IMPORTANT NOTICE on Page 1, and the PERSONAL PRIVACY LAW on Page 5. Then complete pages 1-5 of the application. Page 6 is for Agency use ONLY. Attached is an application to register to vote. Applying to register or declining to register to vote will not affect the amount of assistance that you will be given by this agency. DO NOT DETACH THIS FORM FROM YOUR APPLICATION.

INSTRUCTIONS

Please print clearly. Use only blue or black ink. Answer all questions completely. RETURN YOUR APPLICATION AS SOON AS POSSIBLE {Remember HEAP funds are limited and program closes once money available is finished).

ALL SHADED SPACES ARE FOR AGENCY USE ONLY. DO NOT WRITE IN THESE AREAS.

FAILURE TO FOLLOW THE DIRECTIONS GIVEN BELOW MAY RESULT IN A PROCESSING DELAY OR DENIAL OF YOUR APPLICATION

PAGE 1. Section 1: Household Composition

#1-3 If there is information printed in items #1 through #2 and it is incorrect, cross it out and print the correct information. If there is no information in items #1 through #2, print your full name, complete address (including apartment number). Fill in your date of birth, sex, social security number and county. In #3, write in mailing address (i.e. PO Box) if different from #2.

#4 Provide a phone number where you can be reached.

PAGE 2

#5 List other names you have been known to use.

#6 Report the total number of people who live in your household including yourself.

#7 List the names, birth dates, sex and Social Security numbers of all persons living in your household. DO NOT INCLUDE YOURSELF. All household members age 18 and over must have a social security number.

#8 Check YES or NO to the question concerning disability, and age of household members, including yourself. Indicate the name of the person for whom you answer yes.

#9 Check YES or NO to indicate whether anyone in your household is receiving Food Stamps.

#10 Check YES or NO to indicate whether anyone in your household is receiving Public Assistance

PAGE 3 - Section 2: Household Income

BE SURE TO CHECK YES OR NO TO EVERY QUESTION IN SECTION 2. When reporting income, give total yearly, monthly and weekly amounts according to application requirement. Remember to include the name of the person who receives the income.

Income includes any check(s) or cash which is (are) directly given to you or deposited into your bank account and interest or dividends earned even if these remain in your account.

When reporting Social Security benefits include the amount you receive in your check and the amount you pay for Medicare Part B premium(s).

If you or a member of your household receives a pension, report the name of the union or company.

If you are paying Home Health care or Medicaid Surplus Services, you may be eligible for a deduction from your gross income amount Please attach a copy of the canceled check or Medicaid surplus receipt to the application.

If you are receiving rental income you may be entitled to certain deductions (mortgage interest, property taxes, property insurance, water and sewer). To receive these deductions you must apply in person and bring documentation.

If you or anyone in your household receives wages (income from employment), you must report the name and address of the employer and the amount of monthly wages (before taxes). Please attach to your application copies of paystubs for the current month.

Report all other sources of income not included above.

PAGE 4 - Section 3: Housing

#1 Check the appropriate box for the type of housing you live in.

NOTE IF YOUR HOUSEHOLD RECEIVES SCRIE PLEASE DO NOT CHECK SUBSIDIZED HOUSING.

#2 Report your monthly rent or mortgage payment. If you have no rent or mortgage payment, check “NONE”.

#3 Provide name of apartment building or project, if applicable.

Section 4: Heat and Utility Information

Complete EITHER A, if you pay for heating, OR B IF YOU PAY FOR UTILITIES ONLY. For C, Check YES or NO if your electricity is used to run the furnace.

PAGE 5

Carefully read the information on page 5 of the application.

Sign your application on the line provided. If your signature is an X, please have a witness sign next to it. If assigning power of attorney to another person, please include a letter of verification with your application.

PAGE 6

MAIL YOUR COMPLETED APPLICATION TO:

Department for the Aging
HEAP
2 Lafayette Street, 16th Floor
New York, Non York 10007.

ADDITIONAL INFORMATION

If you have any questions, or you need assistance in completing the application, please contact the Department for the Aging at (212) 442-1000. If you are facing a heat related utility shut-off or have no heating fuel, call the HRA Infoline at (718) 291-1900 for appropriate referral.

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