LIHEAP Forms and Publications

HSEA 1

LIHEAP Application Form

(Spanish)

HSEA 4

Energy Assistance Affidavit

(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian)

HSEA 6

Zero Income Statement

(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian)

HSEA 18

How It Works and Who Can Apply

(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian)

HSEA 34

Vendor Agreement

HSEA 34U

Vendor Agreement (Utility)

HSEA 36

Landlord Statement

(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian)

HSEA 40

DCED/DHS Crisis Interface Referral Form

OIG 189

Overpayment Referral

PA 1796

Household Composition Verification Statement

(Spanish) (Chinese) (Russian) (Vietnamese) (Arabic) (Cambodian)

PWEA 35

LIHEAP Computation Worksheet

PWEA 37

LIHEAP Program Refund

PWEA 41

Low-Income Home Energy Assistance Program (LIHEAP) Electronic Funds Transfer Application Form