LIHEAP Application Form

Click on LIHEAP Application for a fillable .pdf form that you can complete and email to your local Direct Service Provider to apply for a LIHEAP benefit. For instructions on how to complete the application form, click here.

To find a Provider in your area, click here.

The items you will need to provide in order to complete the LIHEAP application process are:

  • Names/birthdates for all household members
  • Social Security numbers for all household members
  • Heating Energy Vendor Name/Account number (utility bill)
  • Electric Vendor Name/Account number (utility bill)
  • Verification of residence address (utility bill)
  • Income verification for the previous month (check stubs, SS/SSI award letters, etc.)

If you have any questions regarding the application form, application form instructions or the application process, please call 375-7382.