PY25 LIHEAP Screening

Welcome to Project NOW's Pre-Screening Eligibility for LIHEAP Assistance.

Please note that completing this form does not guarantee assistance. All eligibility factors will need to be reviewed to determine approval for assistance.

To serve your request in a timely manner, please have your household's Social Security numbers, income details, and utility bills readily available to upload throughout this application. Allow up to 30 days for the review of your application. If you are at risk of disconnection, we strongly recommend contacting one of our offices directly to schedule an appointment with an intake worker to avoid any delays in processing.

It is important to provide the most accurate contact information during this application, as we may need to follow up with you regarding the information you provide.

Head of Household*

Please Submit a copy of Household Member's SSN*

Has Head of Household received any income in the last 30 days?*

YesNo

Please select what type of income:*

Please submit all income for the Head of Household for the last 30 days*

When was the last date Head of Household received income?*

Select DateNever

Date:*

Date

Has this person received any cash for work performed in the last 30 days? Examples include babysitting, lawn care, snow removal, scrap metal, etc.*

YesNo

Has this person received any cash gifts in the last 30 days? Examples include babysitting, lawn care, snow removal, scrap metal, etc.*

YesNo

Has this person received any loans in the last 30 days?*

YesNo

Please tell us how your household has met the following household expenses in the last 30 days. *

I certify the information provided above for the adult zero income household member is true and a complete statement of facts.*

Yes

I understand: I may be required to provide proof of any information given for the adult zero income household member. False information will invalidate this form and may require the return of any benefits received based on the false information.*

Yes

I understand all adult household members are subject to further verification of the income information provided.*

Yes

I have additional household members:*

NoYes

Household Member #2*

Please Submit a copy of Household Member #2's SSN

Has Household Member #2 received any income in the last 30 days?*

YesNo

Please select what type of income:*

Please submit all income for Household Member #2 for the last 30 days

When was the last date Household Member #2 received income?*

Select DateNever

Date:*

Date

Has this person received any cash for work performed in the last 30 days? Examples include babysitting, lawn care, snow removal, scrap metal, etc.*

YesNo

Has this person received any cash gifts in the last 30 days? Examples include babysitting, lawn care, snow removal, scrap metal, etc.*

YesNo

Has this person received any loans in the last 30 days?*

YesNo

Please tell us how your household has met the following household expenses in the last 30 days. *

I certify the information provided above for the adult zero income household member is true and a complete statement of facts.*

Yes

I understand: I may be required to provide proof of any information given for the adult zero income household member. False information will invalidate this form and may require the return of any benefits received based on the false information.*

Yes

I understand all adult household members are subject to further verification of the income information provided.*

Yes

I have additional household members:*

NoYes

Household Member #3*

Please Submit a copy of Household Member #3's SSN

Has Household Member #3 received any income in the last 30 days?*

YesNo

Please select what type of income:*

Please submit all income for Household Member #3 for the last 30 days

When was the last date Household Member #3 received income?*

Select DateNever

Date:*

Date

Has this person received any cash for work performed in the last 30 days? Examples include babysitting, lawn care, snow removal, scrap metal, etc.*

YesNo

Has this person received any cash gifts in the last 30 days? Examples include babysitting, lawn care, snow removal, scrap metal, etc.*

YesNo

Has this person received any loans in the last 30 days?*

YesNo

Please tell us how your household has met the following household expenses in the last 30 days. *

I certify the information provided above for the adult zero income household member is true and a complete statement of facts.*

Yes

I understand: I may be required to provide proof of any information given for the adult zero income household member. False information will invalidate this form and may require the return of any benefits received based on the false information.*

Yes

I understand all adult household members are subject to further verification of the income information provided.*

Yes

I have additional household members:*

NoYes

Household Member #4*

Please Submit a copy of Household Member #4's SSN

Has Household Member #4 received any income in the last 30 days?*

YesNo

Please select what type of income:*

Please submit all income for Household Member #4 for the last 30 days

When was the last date Household Member #4 received income?*

Select DateNever

Date:*

Date

Has this person received any cash for work performed in the last 30 days? Examples include babysitting, lawn care, snow removal, scrap metal, etc.*

YesNo

Has this person received any cash gifts in the last 30 days? Examples include babysitting, lawn care, snow removal, scrap metal, etc.*

YesNo

Has this person received any loans in the last 30 days?*

YesNo

Please tell us how your household has met the following household expenses in the last 30 days. *

I certify the information provided above for the adult zero income household member is true and a complete statement of facts.*

Yes

I understand: I may be required to provide proof of any information given for the adult zero income household member. False information will invalidate this form and may require the return of any benefits received based on the false information.*

Yes

I understand all adult household members are subject to further verification of the income information provided.*

Yes

I have additional household members:*

NoYes

Household Member #5*

Please Submit a copy of Household Member #5's SSN

Has Household Member #5 received any income in the last 30 days?*

YesNo

Please select what type of income:*

Please submit all income for Household Member #5 for the last 30 days

When was the last date Household Member #5 received income?*

Select DateNever

Date:*

Date

Has this person received any cash for work performed in the last 30 days? Examples include babysitting, lawn care, snow removal, scrap metal, etc.*

YesNo

Has this person received any cash gifts in the last 30 days? Examples include babysitting, lawn care, snow removal, scrap metal, etc.*

YesNo

Has this person received any loans in the last 30 days?*

YesNo

Please tell us how your household has met the following household expenses in the last 30 days. *

I certify the information provided above for the adult zero income household member is true and a complete statement of facts.*

Yes

I understand: I may be required to provide proof of any information given for the adult zero income household member. False information will invalidate this form and may require the return of any benefits received based on the false information.*

Yes

I understand all adult household members are subject to further verification of the income information provided.*

Yes

I have additional household members:*

NoYes

How many additional household members do you have?*

The pre-screening only allows up to 5 household members to be entered. A member of our Outreach Team will reach out to you for more information.

Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Ownership*

How much is your rent?*

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

How do you cool your home in the summer?*

Central Air ConditioningWindow / Wall UnitNone

How many bedrooms does your home have?*

How many window/wall air conditioners do you have?*

Where are your window/wall units located?*

Primary Vendor (How you heat your home)*

Secondary Vendor (Electricity)*

Please Submit a copy of your utility bill

IMPORTANT NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under the Low Income Home Energy Assistance Act of 1981 as amended. Disclosure of this information is REQUIRED. Failure to provide any information will result in this application not being processed. This application has been approved by the State Forms Management Center.

APPLICANT STATEMENT: I certify that the information I have provided above is an accurate and complete disclosure of the requested information. I also certify that every household member in the application is either a US citizen or an eligible Illinois resident regardless of immigration status according to the LIHEAP/IHWAP/LIHWAP rules. I authorize this agency to verify the information and contact my utility/fuel supplier, landlord, employer and/or other sources for verification or additional information and to exchange information contained in or otherwise used regarding my application and participation in LIHEAP/IHWAP/LIHWAP. I also authorize the Department of Commerce & Economic Opportunity and my utility/fuel supplier to share my usage and bill information during the twenty-four (24) month period prior to and twelve (12) month period after the date of my application submittal and/or completion of LIHEAP and IHWAP services for the purpose of program evaluation and analysis. I have received information outlining my appeal rights. I understand that filling out this application does not guarantee that my household will receive assistance. The purpose of this document is to provide a summary of the application to the customer for future reference.

Signature*

Date*

Date

I acknowledge that my application cannot be reviewed until I have submitted all household Social Security cards, household income documentation for the past 30 days, and a current utility bill. I understand that I may also be asked to provide additional information following the review of my application.*

Yes

Project NOW LIHEAP Eligibility Screening

Tell Us About Your Household

PLEASE READ AND SIGN