Attachment A - LIHWAP Sample Household Application

Attachment A – Sample Household Application Template

Grantee Note: This Sample Household Application Template is not a required document; it is a resource that can be adapted by LIHWAP grantees and subgrantees as they work to launch their programs. OCS strongly encourages LIHWAP grantees and subgrantees to work with their own legal counsel, when necessary, in adapting this sample household application template or creating their own LIHWAP application.

Sample Template

[NAME OF AGENCY]

Household Water Assistance Application

([Agency Name

City, State, zip code, phone number, email address]

Grantee Note: This agency information above should generally be for the local administering agency. Any phone number or email address should if possible be staffed and have capacity to provide or connect potential household applicants to application intake assistance.)

What is this program?

[NAME OF STATE OR COMMUNITY] Household Water Assistance Program is part of a new federally-funded American Rescue Plan program that provides assistance to help households to pay water and wastewater bills. Depending on your income and specific needs, [NAME OF STATE OR COMMUNITY] you may be qualified for assistance to help:

• Reconnect Household Water Services – If your household water services have been disconnected because of past due water bills, grant funds may be available up to $____ to pay off the balance, including fees to reconnect household water services.

• Prevent Disconnection of Household Water Services – If you have received a notice that your water services will be disconnected due to a past due balance and you can’t afford to pay, grant funds may be available to pay all or part of your water bill.

• Help Reduce Current Household Water Bills – If you are unable to afford your current water bills and meet other household needs, you may qualify for temporary assistance to pay some or all of your current water bills.

Who is this program for?

Households may receive assistance based on household income and current water bills. Anyone may apply for services and there are no fees associated. [NAME OF GRANTEE] gives priority consideration to households with the highest water bills as a portion of their household income and also gives special consideration to households with young children, households that include a person with disabilities, or households with elderly residents.

[Grantee Note: The description of services and priority populations above would be customized based on priority populations identified in the LIHWAP Grantee Plan for the State, Territory or Tribe.]

Application for household water assistance

Follow the steps below to apply for assistance

1. Prepare

To fill out this application, you’ll need the information below.

Information about your water service:

If you pay a water provider directly:

• Water provider name, contact information, and account number(s); and

• A copy of your most recent bill(s)

-- OR –

If your water bill is paid as an itemized portion of your rent:

• A copy of your rental/lease agreement showing the breakdown of your rental bill including water service

-- OR –

If your household rents and does not pay a separate water bill:

• Your landlord name and contact information; and

• A copy of your most recent rental receipt or lease agreement stating water service coverage and cost

Information about your household:

The term “household” means any individual or group of individuals who are living together as one economic unit for whom residential drinking water and/or wastewater services is customarily purchased in common or who make undesignated payments for those services in the form of rent.

For every person living in your home:

• First and last name

• Date of birth

• Social Security Number (if available)

• Gender

• Ethnicity

• Race

• Disability status

Please note that if you do not have all of the information above for every household member, you may still be eligible for assistance for some or all household members. Please contact _______ if you have questions or concerns.

[Grantee Note: A Social Security Number may be requested, required or alternate verification procedures may be allowed depending upon the policies and procedures included in the LIHWAP Grant Plan for the State, Territory, or Tribe. Grantees are encouraged to provide contact information for an intake worker if grantees have questions.]

Documentation of Income Eligibility

If you have previously applied for and are currently receiving assistance through any of the following programs, you automatically meet income eligibility requirements.

• Low Income Household Energy Assistance Program (LIHEAP)

• Supplemental Nutrition Assistance (SNAP)

• Supplemental Security income (SSI)

• Temporary Assistance for Needy Families (TANF)

• Means-Tested Veterans Programs

If you are not currently enrolled in any of the programs identified above, you will need to submit proof of household income, including copies of relevant income sources.

Please note that a household may be eligible for assistance if at least one member is a U.S. Citizen or legal permanent resident, living in [Name of State or Community].

[Grantee Note: The list above would be customized based on programs included in the LIHWAP Grantee Plan.]

2. Apply
   Complete this application. Depending on the amount of people in your household and the amount of information you provide, this should take about 15 to 45 minutes.

Options for submitting the application include the following:

• Drop-off – A completed application may be delivered to the following address: ____________

• Intake Appointment – Appointments for a 15-minute intake process (either by phone or in-person) may be scheduled by calling {###-###-####]

• Online Portal – Copies of completed applications and supporting documentation may be submitted online via the following encrypted application portal.

After you submit your application, you will be notified within ____ business days whether your application has been approved, if more information is needed, or if the application is not eligible or approved for payment at this time. If your application is not approved and you would like to appeal the decision, information on an appeal process will be provided.

[Grantee Note: These instructions would need to be customized based on the organization’s procedures and may include links.]

______

[STATE or LOCAL AGENCY NAME]

Household Water Assistance Program Application

A. BASIC INFORMTION

1. Your first name	2. Your last name

3. Your address (This is where you receive water service)
Street address		Apartment/Unit
City	State	Zip code
Is this the best address for you to receive mail? ☐ Yes, send mail to this address ☐ No, use a different address for mail (provide below) The address where you’d like to receive mail (if different)
Street address			Apartment/Unit
City	State		Zip code

	4. Your phone number
			May we leave a detailed voice message? ☐ Yes ☐ No May we send you text messages at this number with updates on the status of your application? ☐ Yes ☐ No
5. Your email This is optional and will be used to communicate important information during the application process.

6. When is the best time for us to contact you? (Check all that apply) The purpose will be to schedule an interview for benefits determination or to review application information submitted if needed. We will do our best to contact you about your LIHWAP application at a time you’ve specified.

Monday ☐ 7am-9am ☐ 9am-noon ☐ noon-2pm ☐ 2pm-5pm ☐ after 5pm

Tuesday ☐ 7am-9am ☐ 9am-noon ☐ noon-2pm ☐ 2pm-5pm ☐ after 5pm

Wednesday ☐ 7am-9am ☐ 9am-noon ☐ noon-2pm ☐ 2pm-5pm ☐ after 5pm

Thursday ☐ 7am-9am ☐ 9am-noon ☐ noon-2pm ☐ 2pm-5pm ☐ after 5pm

Friday ☐ 7am-9am ☐ 9am-noon ☐ noon-2pm ☐ 2pm-5pm ☐ after 5pm

Saturday ☐ 7am-9am ☐ 9am-noon ☐ noon-2pm ☐ 2pm-5pm ☐ after 5pm

Sunday ☐ 7am-9am ☐ 9am-noon ☐ noon-2pm ☐ 2pm-5pm ☐ after 5pm

[Grantee Note: The contact times above should only be included if the program has the ability to customize contact times, including during weekends and evening business hours. Grantees should also customize and use only if necessary based on grantee procedures. For example, if a grantee does not routinely conduct intake interviews, this reference may be removed ]

7. What is your total estimated household annual income?

$

8. How many people are in your household? For purposes of LIHWAP eligibility and benefit determinations, the term “household” means any individual or group of individuals who are living together as one economic unit for whom residential drinking water and/or wastewater services is customarily purchased in common or who make undesignated payments for those services in the form of rent.

B. WATER SERVICE INFORMATION

9. What is your current household drinking water assistance need?

☐ My household drinking water has been shut off due to a past due bill.

☐ My household drinking water services are on, but scheduled to be shut off.

Disconnection is scheduled for:

MM

DD

YYYY

☐ My household drinking water services are on, but we need help paying future bills.

10. What is your current household wastewater assistance need?

☐ My household wastewater service has been shut off due to a past due bill.
☐ My household wastewater services are on, but scheduled to be shut off.	Disconnection is scheduled for:
	MM	DD	YYYY

☐ My household wastewater services are on, but we need help paying future bills. [Grantee Note: This sample form asks separate question about drinking water and wastewater services, but grantees may combine these questions into a single set of questions about household water services if all households in your service area pay a single combined bill for both drinking water and wastewater services.] 11. Who do you pay for drinking water and wastewater removal services?
☐ I pay a water utility company directly (provide company name and account number(s) below)
Household Drinking Water Utility Company Please provide a copy of your most recent bill.
Household Wastewater Utility Company (if different from the company above) Please provide a copy of your most recent bill.
Water account number(s) List all account numbers for your household’s water.

10. Who do you pay for clean water and wastewater removal services?
☐ I pay a water utility company directly (provide company name and account number(s) below)
Water utility company Please provide a copy of your most recent bill.
Water account number(s) List all account numbers for your household’s water.

☐ My household rents our home and does not have a separate water bill (provide landlord name and contact information below) Please provide a copy of your most recent rental receipt or lease stating that water is covered in your rental fee.
Landlord name or company
Landlord address	Street address
	City		State		Zip code
Landlord phone number
Are you behind on paying your rent? ☐ No, I am not behind on my rent ☐ Yes, I am behind on and need help paying my rent

[Grantee Note: While the Low Income Household Water Assistance Program funds can be used to pay for rent, funds can be used to pay the portion of a rental payment that covers a water payment. Grantees are encouraged to coordinate with other programs, such as Emergency Rental Assistance Program, the Low Income Home Energy Assistance Program and the Community Services Block Grant to help address a range of household needs.]

C. HOUSEHOLD INCOME:

15) Is anyone in your household currently enrolled in any of the following program(s)? This information helps us determine eligibility and may help us to provide faster assistance because you have already provided information on your income and household in applying for these programs. Check all that apply:

Program	Yes	No	Unsure
Low Income Household Energy Assistance Program (LIHEAP)
Supplemental Nutrition Assistance (SNAP)
Supplemental Security income (SSI)
Temporary Assistance for Needy Families (TANF)
Means-Tested Veterans Programs
Other

If you answered yes to any of the programs above, you can provide an eligibility notice for one of these programs, and there have been no changes to the number of people in your householdyou do not need to fill out question 16 or provide additional documents. If you answered no to all of the programs above, please complete question 16 below and provide proof of income.

Grantee Note: Grantees are encouraged to establish procedures to accept documentation such as a notice of eligibility for one or more of these programs within the last year. Grantees that have not established such procedures may consult with their OCS program contact person and submit amendments to the LIHWAP grantee plan at a later date as needed.

16) Please check each box in the table below for all sources of household income.

Also attach/submit proof of all household income listed below. Proof of income for each household member for the [INSERT TIMEFRAME], such as a paystub, Social Security letter, child support letter, unemployment letter, self-employment documentation, etc.)

Income Source	Check if “yes” for household
Employment (wages/paystub)
Social Security (benefit letter)
Child Support (court order)
Alimony (court order)
Unemployment (benefit letter)
Pension
Workers compensation (benefit letter)
Self-Employment (tax return)
Zero Income (affidavit)
Other (please specify)

Grantee Note: The income sources provided above are examples only. Actual income sources must be consistent with the income sources included in the LIHWAP Grantee plan for the State, Territory or Tribe.

Explanation (please add any information you need to explain the responses you have provided on this application):

CERTIFICATION:

I attest that the information stated above is true and accurate and understand that the above information, if misrepresented, or incomplete, may be grounds for immediate application termination and/or could result in penalties as specified by law. I also agree to the additional Release of Information to the water provider as necessary to process payment and verify services provided. In addition, I agree that data from this form (not including my personal identifying information) may be used for reporting or program evaluation purposes.

Applicant Signature Date

Grantee Note: The specific language for the certification above may need to be adapted based on the policies and procedures of the the State, Territory or Tribe, OCS recommends a review by the legal counsel for the state, territory or tribe if possible

Grantee Note: Information on household members should be collected during the intake process, but may be customized based on the procedures and policies of the grantee. For example if SSN is not required for all household members, this may be modified. OCS recommends maintaining the Ethnicity and Race categories as presented as this information will be needed for reporting purposes.

ATTACHMENT 1: LIST OF ALL HOUSEHOLD MEMBERS- Include second page for additional household members

*Household: For purposes of LIHWAP eligibility and benefit determinations, the term “household” means any individual or group of individuals who are living together as one economic unit for whom residential drinking water and/or wastewater services is customarily purchased in common or who make undesignated payments for those services in the form of rent.

1. (Primary/ Applicant)	Name	DOB	SSN	Gender
				☐Female ☐Male ☐ Other
	Ethnicity	Race		Does this Person Have a Disability?
	☐ Hispanic, Latino or Spanish Origins ☐ Not Hispanic, Latino or Spanish Origins	☐ American Indian or Alaska Native ☐ Asian ☐ Black or African American ☐ Native Hawaiian and Other Pacific Islander ☐ White ☐ Multi-race (two or more of the above) ☐ Other _________________________		☐Yes ☐No
2.	Name	DOB	SSN	Gender
				☐Female ☐Male ☐ Other
	Ethnicity	Race		Does this Person Have a Disability?
	☐ Hispanic, Latino or Spanish Origins ☐ Not Hispanic, Latino or Spanish Origins	☐ American Indian or Alaska ☐ Native Asian Black or African ☐ American Native Hawaiian and Other Pacific Islander ☐ White ☐ Multi-race (two or more of the above) ☐ Other _________________________		☐Yes ☐No
3.	Name	DOB	SSN	Gender
				☐Female ☐Male ☐ Other
	Ethnicity	Race		Does this Person Have a Disability?
	☐ Hispanic, Latino or Spanish Origins ☐ Not Hispanic, Latino or Spanish Origins	☐ American Indian or Alaska ☐ Native Asian Black or African ☐ American Native Hawaiian and Other Pacific Islander ☐ White ☐ Multi-race (two or more of the above) ☐ Other _________________________		☐Yes ☐No
4.	Name	DOB	SSN	Gender
				☐Female ☐Male ☐ Other
	Ethnicity	Race		Does this Person Have a Disability?
	☐ Hispanic, Latino or Spanish Origins ☐ Not Hispanic, Latino or Spanish Origins	☐ American Indian or Alaska ☐ Native Asian Black or African ☐ American Native Hawaiian and Other Pacific Islander ☐ White ☐ Multi-race (two or more of the above) ☐ Other _________________________		☐Yes ☐No

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Author	Mary
File Modified	0000-00-00
File Created	2022-02-20