LIHEAP Utility Assistance Application Form – 2022

LIHEAP Utility Assistance Application 2024

Step 1 of 4

  • MM slash DD slash YYYY
  • Address where you live (this cannot be a P.O. Box)
  • (SSN)
  • Enter the total number of people living in the household, including yourself
  • Enter the number of people in the household who are
    Ages 0 – 2 YearsAges 3 ‐ 5 yearsAges 6 ‐ 18 yearsAges 19 ‐ 59Ages 60 and olderDisabledNative AmericanSeasonal or Migrant Farmworker
  • Enter the total number of people who receive income
  • Enter the total gross monthly income for all people living in the household:
    TANF / CalWorksSSI / SSPSSA / SSDIPaycheck(s)InterestPensionOther
  • Drop files here or
    Accepted file types: jpg, pdf, png, Max. file size: 8 MB.
      Must be within the past 30 days. If applicable, must include proof of CalFRESH and/or other cash assistance (current Passport to Services or Notice of Action).
    • ENTER THE INFORMATION BELOW FOR ALL HOUSEHOLD MEMBERS. To add a person, click the plus (+) button on the right.
      First NameMiddle InitialLast NameRelation to Applicant (for yourself, write "Self")Date of Birth (MM/DD/YY)Gender (Female, Male, Other, or Unknown/Decline to State)Race (American Indian or Alaska Native, Asian, Black or African American, Native Hawaiian or Other Pacific Islander, White, Multi-Race, Other, or Unknown/Decline to State)Hispanic/Latino/Spanish? (Yes, No, or Unknown/Decline to State)Amount of Gross Income (Before Taxes)Source of Income 
      If yes, you must turn in a current Passport to Services.