**퇴거 통지서가 있거나 이를 받을 예정이라면, 패킷을 제출할 때 Hopelink 담당자에게 그 사실을 알려주십시오.

기본 정보 양식, 신청자

연락처 정보

선호하는 연락 방식은 무엇인가요? 전화 이메일

전화번호: 이메일 주소(해당하는 경우):

(필요한 경우 연락을 드릴 수 있는 유효한 연락처를 제공해주십시오)

Hopelink 프로그램에는처음 신청하시는가요? 예 아니요

전기

천연가스

장작

오일

프로판

이는 기본 열 공급원 작동에 필수적인가요?

전기

현재 거주하시는 가정의 유형은 무엇인가요?

단일 주택, 2세대 주택, 3세대 주택

연립주택

1층 또는 2층 아파트 건물

아래에서 한 가지를 선택해주십시오.

나는 주택을 소유하거나 담보대출을

받고 있다

나는 집을 임대하고 있다(보조금 없음)

나는 보조금을 받는 주택을 소유하고

있다(예: 섹션 8)

예 아니요

예 아니요

가스

3층 이상 아파트 건물

모바일 홈

레저용 차량(RV)

나는 방을 임대하고 있다/나는 방을 전대하고 있다

나는 임시 주택에 살고 있다

현재 거주 상황은 어떻게 설명하실 수 있으신가요?

안정적

위험함(임대료를 지급하는 것이 걱정됨)

주거지 상실(퇴거 절차가 임박하거나 시작됨)

지난해 LIHEAP 에너지 지원을 받으셨나요?

아니요

예. Hopelink 경유

예. 다른 기관 경유

만 18세가 된 가족 구성원 중 아직 고등학교에 다니는 학생이

있으신가요? 그렇다면, 이름(들)을 기재해주십시오:

예 아니요

본 프로그램으로부터 에너지 보전, 에너지 절약 및 주택 내후성 향상 등에 관한 정보를

받으시겠습니까? 예 아니요

귀하께서는 보조 에너지원을 소유하고 있으신가요?

주택 난방을 위해 주로 사용하시는 에너지는 무엇인가요?

신청서의 다음 페이지를 완성하실 때는 반드시 하이라이트된 섹션만 모두 작성해주십시오.

4.

3.

Washington State Department of Commerce, Low Income Home Energy Assistance Program (LIHEAP) HOUSEHOLD INFORMATION FORM (HIF) (7/2016)

*Agency: Assistance Provided:*Energy Assistance OR*Crisis - Imminent OR*Crisis - No HeatOther Emergency ServicesConservation Education

Interested in WeatherizationTribal MemberReceived Food AssistanceHeat with rentReceived EAP last program year

File Number:

*County: Certification Date:

SECTION A: Household Contact & Eligibility Information*Primary Applicant:

(Last Name) (First Name) (Middle Initial)*Residence Address:

City, State, Zip:

Mailing Address:(If different)

City, State, Zip:

Phone Number: Message Phone: Lived at Residence:( ) - ( ) - Years: Months: *Housing Status:

1 Own/buy2 Subsidized3 Rental4 Roomer/Boarder5 Temp Housing

*Housing Type:1 1-3 Family2 4+ Family3 Hi-Rise4 Mobile5 RV

*Income/Benefits:SSI Earned IncomeTANF PensionGA Self EmployedVA Child SupportSoc. Sec. UnemploymentMilitary Other

*Total Number of People inthe Household:

*Household’s Monthly Income:

$Cost per Month:$

Number of Bedrooms:

Target Group #1: Yes No

Target Group #2: Yes No

*Primary Heat Source:1 Electric 4 Oil 2 Natural Gas 5 Wood 3 Propane 6 Coal

*Annual Heat Cost: $_____________ Back Up Heat Cost

Total Energy Cost: $_____________ Used Surrogate Data

*Total Annual Electric Costs: $_____________

SECTION B: Energy Assistance (EAP)Staff: P.O.#:

HOUSEHOLD ELIGIBILITY AMOUNT: $_____________Payment to Vendor(s): Direct Pay to Applicant: $_____________

#1 Acct. #: $_____________

#2 Acct. #: $_____________

TOTAL EAP PAID TO DATE: $_____________

SECTION C: Other Emergency Services (OES)Staff: P.O.#:

Heat System: Repairs Vendor #: $_____________

Replacement Vendor #: $_____________

Other Repairs & Services: Vendor #: $_____________

Vendor #: $_____________

Shelter Assistance: Vendor #: $_____________

TOTAL OES PAID TO DATE: $_____________I certify that I have provided and reviewed all information on each page of this document and it is accurate to the best of my knowledge. I understand that I may be subject to criminal prosecution if I have knowingly provided false information. I further understand that I may request a Fair Hearing if the provision of the above information is not acted on to determine my eligibility within a reasonable time or if I do not receive benefits for which I feel I am eligible. I give my permission for this agency and Washington State Department of Commerce (COMMERCE) to request/release necessary information that may result in my receiving benefits from this assistance request and from similar and related programs administered by the State of Washington, including food assistance. I also give the above listed heating vendor(s) permission to establish a line of credit, and/or to release my account information to this agency or COMMERCE for current and future data analysis and eligibility determination. If the vendor is Seattle City Light, the permission to release customer billing and consumption information is allowed for up to six months from the date of this application. I understand that provision of my social security number is necessary to avoid duplicate energy assistance benefit payments to the same applicant household. I hereby authorize energy program staff to also use my social security number for income verification purposes (including Employment Security Unemployment Insurance and DSHS Food Assistance). I further authorize this agency and COMMERCE to use my personal information within their organizations for the purpose of identifying and reporting unduplicated non-personal applicant data.

(Note: All fields designated with an (*) are required information.)

*(Last Name) (First Name) (Middle Initial)

:*Residence Address:

City, State, Zip:City, State, Zip:

:Mailing Address:(If different(( )

City, State, Zip:

Phone Number: Lived at Residence:

* f i*Total Number of People inthe Household:

Number of Bedrooms:Cost per Month:$

**ApplicaApplicantnt Signature: Signature::

신종 코로나바이러스(COVID-19)의 영향에 따라 신청자가 양식에 직접 인쇄체로 이름

을 기재하고 서명할 수 없는 경우 전자적 서명을 받는 것이 허용됩니다. 전자적으로 서명

하기를 원하신다면, 이 칸에 표시함으로써 아래 성명서에 동의해주십시오.

DaDatte:e: "신종 코로나바이러스

(COVID-19)로 인해 본인은 자신

의 전자적 서명 또는 키보드로 입

력된 이름으로 본 신청서를 확인 및 승인함을 인정합니다"

Washington State Department of Commerce, Low Income Home Energy Assistance Program (LIHEAP)Household Member Information Form (10/2015)

*Last Name *First Name MI *SSN (required if primary)

__ __ __-__ __-__ __ __ __*Relation to Primary

SelfSpousePartnerChildOther RelativeOther Non-Relative

*GenderMaleFemale

RaceAmerican Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMulti-RaceOther

Education (24 Years or Older)0-89-12 Non-GraduateHigh School Graduate/GED12+ Some Post-Secondary2 or 4 Year College Graduate

Included in CalculationYes No

DisabledYes No

EthnicityHispanic or LatinoNot Hispanic or Latino

Military VeteranYes No

Health InsuranceYes No

* Last Name * First Name MI *SSN (required if secondary)__ __ __-__ __-__ __ __ __

*DOB

*Relation to PrimarySpousePartnerChildOther RelativeOther Non-Relative

Secondary ApplicantYes No

*GenderMaleFemale

RaceAmerican Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMulti-RaceOther

Education (24 Years or Older)0-89-12 Non-GraduateHigh School Graduate/GED12+ Some Post-Secondary2 or 4 Year College Graduate

Included in CalculationYes No

Yes No

EthnicityHispanic or LatinoNot Hispanic or Latino

Military VeteranYes No

Health InsuranceYes No

* Last Name * First Name MI SSN__ __ __-__ __-__ __ __ __

*DOB

__ __ / __ __ / __ __ __ __

*Relation to PrimarySpousePartnerChildOther RelativeOther Non-Relative

*GenderMaleFemale

RaceAmerican Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMulti-RaceOther

Education (24 Years or Older)0-89-12 Non-GraduateHigh School Graduate/GED12+ Some Post-Secondary2 or 4 Year College Graduate

Included in CalculationYes No

DisabledYes No

EthnicityHispanic or LatinoNot Hispanic or Latino

Military VeteranYes No

Health InsuranceYes No

* Last Name * First Name MI SSN__ __ __-__ __-__ __ __ __

*DOB__ __ / __ __ / __ __ __ __

*Relation to PrimarySpousePartnerChildOther RelativeOther Non-Relative

*GenderMaleFemale

RaceAmerican Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMulti-RaceOther

Education (24 Years or Older)0-89-12 Non-GraduateHigh School Graduate/GED12+ Some Post-Secondary2 or 4 Year College Graduate

Included in CalculationYes No

DisabledYes No

EthnicityHispanic or LatinoNot Hispanic or Latino

Military VeteranYes No

Health InsuranceYes No

* Last Name * First Name MI SSN__ __ __-__ __-__ __ __ __

*DOB__ __ / __ __ / __ __ __ __

*Relation to PrimarySpousePartnerChildOther RelativeOther Non-Relative

*GenderMaleFemale

RaceAmerican Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMulti-RaceOther

Education (24 Years or Older)0-89-12 Non-GraduateHigh School Graduate/GED12+ Some Post-Secondary2 or 4 Year College Graduate

Included in CalculationYes No

DisabledYes No

EthnicityHispanic or LatinoNot Hispanic or Latino

Military VeteranYes No

Health InsuranceYes No

* Last Name * First Name MI SSN__ __ __-__ __-__ __ __ __

*DOB__ __ / __ __ / __ __ __ __

*Relation to PrimarySpousePartnerChildOther RelativeOther Non-Relative

*GenderMaleFemale

RaceAmerican Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteMulti-RaceOther

Education (24 Years or Older)0-89-12 Non-GraduateHigh School Graduate/GED12+ Some Post-Secondary2 or 4 Year College Graduate

Included in CalculationYes No

DisabledYes No

EthnicityHispanic or LatinoNot Hispanic or Latino

Military VeteranYes No

Health InsuranceYes No

Note: All fields designated with an (*) are required information. SSN’s for the primary and secondary applicants are also required.

*Gender*Relation to Primary Race

Ethnicity

Education (24 Years or Older)0 8

Included in Calculation

Disabled

Military VeteranY N

Health Insurance

**DDOBOB

__ __ / __ __ / __ __ __ __

*DOB

*Relation to Primary *Gender

Ethnicity

Race Education (24 Years or Older)

Included in Calculation

__ __ / __ __ / __ __ __ __

Military Veteran

Health InsuranceSecondary Applicant

*DOB

*Relation to Primary *Gender

Ethnicity

Race Education (24 Years or Older)0 8

Included in Calculation

Disabled

Military Veteran

Health Insurance

**Last Name **First Name

* Last Name * First Name

* Last Name * First Name

DiDissaabbleledd

SECTION A: HOUSEHOLD INFORMATION (Required)

SECTION B: BILLING INFORMATION (Required)

INCOMEINCOME SOURCE(S)ANNUAL USAGE COSTENERGY TYPEHOUSING TYPEHOUSING STATUS

PSE HELP APPLICATION

PRIMARY

AGENCY # (Required) #ELIFETADNOITACIFITRECYTNUOC (Optional)

*Note: If you answered No to questions 1 or 2, PSE will automaticallysign you up for service as the primary and contact agency with yournew account number. PSE may contact landlord to avoiddiscrepancies. A Deposit may be requested. Payment arrangementsmay be made on the deposit by contacting customer service prior tothe due date @ 1-888-225-5773 M - F 7:30 am - 6:30 pm.

If the Applicant is the Primary on the PSE bill pleaseskip to Section C.

3333 Goldenrod: Agencies Green: PSE Blue: Customer

Back Up Energy Cost

Used Surrogate Data

TOTAL # PEOPLE IN HOUSEHOLD HOUSEHOLD MEMBERS (VOLUNTARY) # of people in household who are:

APPLICANT'S NAME (LAST) (FIRST) (MIDDLE INITIAL) SSN DATE OF BIRTH (MM/DD/YY)

SECTION C: HELP

RESIDENCE ADDRESS PIZETATSYTIC

PIZETATSYTIC)ECNEDISERNAHTTNEREFFIDFI(SSERDDAGNILIAM

ENOHPEGASSEMENOHP

Is the Primary name listed on the PSE bill:1. At least 18 years of age or emancipated*? No ___ Yes ___2. Still living at residence*? No ___ Yes ___3. Spouse of applicant? No ___ Yes ___4. Deceased spouse of applicant No ___ Yes ___(If you answer "yes" to #4, the Applicants

‘

name will appear as primary. Their account number will be changed.)

0-2 yrs 3-5 yrs 6-17 yrs 60+ yrs

PRIMARY NAME ON PSE BILL (LAST) (FIRST) (MIDDLE INITIAL) SSN DATE OF BIRTH (MM/DD/YY)

STAFF NAME

PURCHASE ORDER #

RECEIVED LIHEAP THIS PROGRAM YEAR?: YES NO

$__________

CO-CUSTOMER

APPLICANT'S SIGNATURE DATE

NOT LISTED**Note: PSE will sign you up for service as co-customer, or primary dependent on

Section B questions 1-4.

)()(

$$$$$$

#1 Gas Acct. #

#2 Electric Acct. #

vendor #vendor #vendor #vendor #

APPLICANT'S ELIGIBILITY AMOUNT:

1 Own/buy

2 Subsidized

3 Rental

$______ per month

1 1-3 Family

2 4+ Family

3 Hi-Rise

4 Mobile

5 RV

Household's MonthlyIncome

$_________ . ______(If applicable)

1 All Electric

2 Gas + Electric

3 Gas only

4 Electric Base

1 SSI

2

3

4

5

6

TANF

GA

VA

SSA

EI

HOW DOES APPLICANT'S NAME APPEAR ON PSE BILL?

INTERESTED IN HOME WEATHERIZATION?: YES NO

SECOND ADULT IN HOUSEHOLD (LAST) (FIRST) (MIDDLE INITIAL) SSN DATE OF BIRTH (MM/DD/YY)

TOTAL PAID TO DATE:

Gas $__________Electric $__________LIHEAPHeat Cost $__________

Total $__________

7 PEN

8 MIL

9 CS

10 UI

11 Self Employ

12 Other

and review v accur

Disabled

EMAIL ADDRESS

06/19

LIVED AT RESIDENCE (MM/DD/YY)

LAST FOUR OF SSN

LAST FOUR OF SSN

LAST FOUR OF SSN

DATE MOVED INTO RESIDENCE (MM/DD/YY)

Certify eligibility for two years after demonstrating a steady household income.Not Applicable: X

No Steady Income Source(s) & Occupant(s):

#1 Gas Acct. #

#2 Electric Acct. #

3333 09/19

APPLICANT’S TOTAL ELIGIBILITY AMOUNT:

APPLICANT'S SIGNATURE DATE

APPLICANT'S NAME (LAST) LAS FOUR OF SSNTST DATE OF BIRTH (MM/DD/YY)

SECOND ADULT IN HOUSEHOLD (LAST) (FIRST) LAS FOUR OF SSNTST DATE OF BIRTH (MM/DD/YY)

RESIDENCE ADDRESS TTIC

REFFIDFI(SSERDDAGNILIAM ECNEDISERNAHTTNE IZ

IZ

YTIC

HOW DOES APPLICANT'S NAME APPEAR ON PSE BILL?

TOTAL # PEOPLE IN HOUSEHOLD

_ per month

신종 코로나바이러스(COVID-19)의 영향에 따라 신청자가 양식에 직접 인쇄체로 이

름을 기재하고 서명할 수 없는 경우 전자적 서명을 받는 것이 허용됩니다. 전자적으

로 서명하기를 원하신다면, 이 칸에 표시함으로써 아래 성명서에 동의해주십시오.

"신종 코로나바이러스(COVID-19)로 인해

본인은 자신의 전자적 서명 또는 키보드로

입력된 이름으로 본 신청서를 확인 및 승인함을 인정합니다"

NJarvis

Highlight

•

•

•

•

•

•

••신종 코로나바이러스(COVID-19)의 영향에 따라 신청자가 양식

에 직접 인쇄체로 이름을 기재하고 서명할 수 없는 경우 전자적 서

명을 받는 것이 허용됩니다. 전자적으로 서명하기를 원하신다면,

이 칸에 표시함으로써 아래 성명서에 동의해주십시오.

"신종 코로나바이러스(COVID-19)로 인해

본인은 자신의 전자적 서명 또는 키보드로

입력된 이름으로 본 신청서를 확인 및 승인

함을 인정합니다"