LDSS 3421(Bengali) Home Energy Assistance Program ApplicationLDSS-3421-BE (Rev. 5/20)

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DATE RECEIVED
DATE RECEIVED
APPLICATION DATE
OFFICE UNIT ID WORKER ID CASE TYPE CASE NUMBER REGISTRY NUMBER VERS.
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APPLICATION TYPE: Full Documentation Simplified
Vendor
Collateral Contact
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IS ANYONE IN THE HOUSEHOLD VULNERABLE? Under the age of 6 Age 60 or older Permanently Disabled
Who__________________________________________ Documentation____________________________________________
RESIDENCE – CHECK TYPE OF DOCUMENTATION OBTAINED
Current Rent Receipt w/Name & Address Water, Sewage, or Tax Bill Mortgage Payment Book/Receipts w/Address
Homeowner’s/Renter’s Insurance Policy Copy of Lease w/Address Utility Bill Other _________________________
INCOME DOCUMENTATION/CALCULATION Categorically Eligible: TA SNAP Code A SSI
Comments, resolution activities, income calculation/documentation, verification of emergency for expedited regular benefit, vendor contract, etc. SHOW ALL CALCULATIONS
REGULAR BENEFIT (EMERGENCY USE PART B)
Gross Bi-Weekly Income x 2.166666
Gross Weekly Income x 4.333333
TOTAL INCOME $
No prior application No Changes WMS Inquiry Changes verified How:_______________________________________
Pended START: END: APPROVED DENIED
CERTIFYING AGENCY

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LDSS-3421-BE (Rev. 5/20) 7

NOTES AND INCOME CALCULATION WORKSHEET
FEDERAL REPORTING STATUS OF HOME ENERGY SERVICE
THE HOUSEHOLD HAS ONE OR MORE OF THE FOLLOWING - CHECK ALL THAT APPLY
A disconnect notice. Company Name: ____________________________________________
Disconnection from service. Company Name: ____________________________________
Less than ¼ tank of fuel. Company Name: _____________________________________________
Less than a 10 day supply of fuel. Company Name: __________________________________________________
Out of fuel. Company Name: __________________________________________________
A non-working furnace/boiler/heat system that needs replacement
Electricity as supplemented heating fuel.
Wood as supplemental heating fuel.
Other supplemental heating fuel.
LDSS-3421-BE (Rev. 5/20) 1

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LDSS-3421 (Rev. 5/20) 5
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