ART 4643 ART HEAP Application.pdf

How do you heat your home?

Company/Vendor Account Number Costs included in rent? Shared Meter?

Account Holder’s First Name Account Holder’s Last Name Relationship to Primary Client

If you are currently enrolled in PIPP, do you wish to reverify on this account?

Do you wish to enroll in PIPP and do you have a regulated utility provider?

ENERGY ASSISTANCE PROGRAMS APPLICATION JULY 2025 – MAY 2026

Ohio’s Energy Assistance Programs can help income eligible Ohioans manage their utility bills. The Home Energy Assistance Program (HEAP), and emergency HEAP provide the benefit directly to a customer’s utility bill. The Percentage of Income Payment Plan Plus (PIPP) is an extended payment plan in which customers pay a percentage of their income toward their utility bill each month. If you are looking to improve the energy efficiency of your home to help lower your energy bills, the Home Weatherization Assistance Program (HWAP) or Electric Partnership Program (EPP) may help. For HWAP and EPP, visit energyhelp.ohio.gov to find your local provider and contact them for additional information.

You can apply for the energy assistance programs by visiting energyhelp.ohio.gov and completing the online application, by completing this application and mailing it with copies of documentation to the P.O. Box below, or by scheduling an appointment with your local energy assistance provider or HWAP/EPP provider. Applications completed online or by mail can take up to 12 weeks to process. Please visit energyhelp.ohio.gov for additional information.

Here’s what you’ll need to complete this application:

• Proof of citizenship for each member of the household

• Proof of income for each member of household for either the previous 30 days or 12 months

• Copies of your most recent utility bills

• Disability verification (if applicable)

A household is defined as any individual or group of individuals living together as one economic unit for whom residential energy is customarily purchased in common or who make undesignated payments for energy in the form of rent (Per Section 2603 (5) of the Low-Income Energy Assistance Act of 1981). If you live in federally subsidized housing and have a utility bill in your name, you may be eligible for assistance. A copy of the utility bill or documentation of responsibility (example: copy of your rental agreement/lease or signed letter from your landlord) is required.

For a dwelling unit to be eligible for energy assistance benefits, its primary heat source must be:

• A regulated or unregulated utility (gas and electric).

• A permanent, free-standing fuel tank (oil and propane).

• A legal fireplace (wood).

• A legally vented wood/coal stove or furnace.

Residents of any licensed medical facility (hospital, skilled nursing facility or intermediate care facility) or publicly operated community residence (example: YMCA) are not eligible. Boarding/rooming houses, group homes or emergency shelters are also not eligible.

If eligible, the HEAP benefit amount will depend on federal funding levels, how many people live with you, total household income and the main fuel used. In most cases, benefits are applied directly to the heating bill by the utility company. If you are reverifying your PIPP amount, it will be based on either 10% or 5% of your total household income for the past 30 days, depending on your heating source.

These are the programs you can apply for with this application:

• Home Energy Assistance Program (HEAP).

• Percentage of Income Payment Plan Plus (PIPP).

• Home Weatherization Assistance Program (HWAP).

ENERGY ASSISTANCE PROGRAMS APPLICATION JULY 2025 – MAY 2026

Terms of Agreement I agree To pay my Percentage of Income Payment Plan Plus (PIPP) amount for my electric and/or natural gas service every month.

To go to my local energy assistance provider or to energyhelp.ohio.gov to reapply at least once a year with updated household information, and income documentation in order to remain eligible.

To contact my local energy assistance provider or go online to energyhelp.ohio.gov to report any changes to my total household income or number of household members, within 30 days of the change.

To accept any energy efficiency programs offered by Development or its designated providers, if eligible.

To allow my utility companies to release my name, address, telephone number, household member information, amount of my utility usage, and total past due amount to Development and agencies performing weatherization services and/or provide other energy related services.

To allow Development to release my name, address, telephone number, household member information, and current status to the utility companies, and other energy assistance providers.

To allow Development to share my usage and demographic data with organizations contracted by Development to evaluate the programs administered by Development.

I understand I will not be re-verified if I owe any PIPP payments. I must make up these payments by the next billing cycle, or the due date given to me by my utility companies.

If I miss three or more consecutive payments, I will receive a notice on my bill and have one billing cycle after the notice to make up payments or be dropped from PIPP.

If I do not re-verify my income at least once every 12 months, I will be dropped from PIPP.

If I do not make up missed PIPP payments by my stated anniversary date, I will be dropped from PIPP (I understand the PIPP verification and anniversary dates are printed on the utility bills each month).

If eligible for EPP, I agree and/or understand that enrollment to accept EPP services is required to maintain eligibility for PIPP Plus.

If I make my PIPP payments in full and on time every month, I will receive a credit for 1/24th of my total past-due amount, and I will not need to pay the difference between my PIPP payment and my actual bill amount.

If I reapply for PIPP and I am not eligible, or if I choose to be removed from PIPP, I can enroll in Graduate PIPP for up to 12 months after the date I am removed and still receive credits toward my past-due amounts owed on my utility accounts.

If I move out of the service area for my gas/electric company, I can enroll in the Post PIPP program to make payments on my closed account and receive credits toward the past-due amounts.

I am legally responsible for all past-due amounts on my gas and/or electric accounts and if I am no longer enrolled in PIPP, the past due amounts will become due. If these past-due amounts are not paid in full, the utility companies may use any standard means of collection for the past-due amounts on my accounts.

I may appeal if my application is not decided upon within 12 weeks. I also may appeal within 30 days if I disagree with my benefit amount or if I was denied assistance.

General Authorization An applicant who provides inaccurate income or household composition information risks: being dropped from PIPP and/or other energy assistance programs; being ineligible to reapply for 24 months; having arrearage credits added back on to their utility bill; and/or receiving a bill from their utility (ies) for the full account balance.

I authorize the Tax Commissioner of the Ohio Department of Taxation or any agent or employee designated by the Tax Commissioner of the Ohio Department of Taxation as well as the Director of the Ohio Department of Development or any designated agent or employee of the Director, or the Director of the Ohio Department of Jobs and Family Services or any designated agent or employee of the Director, to disclose to the Director of the Ohio Department of Development or any designated agent or employee of the Director, or to the Tax Commissioner of the Ohio Department of Taxation, or any agent or employee designated by the Tax Commissioner, all of my state of Ohio income tax information. The applicant expressly waives notice of the disclosure(s). The applicant expressly waives the confidentiality provisions of the Ohio Revised Code which might otherwise prohibit disclosure and agrees to hold the Ohio Department of Taxation, the Ohio Department of Development, and the Ohio Department of Jobs and Family Services, and their respective agents and employees harmless with respect to the disclosures herein. This authorization is to be liberally construed and interpreted; any ambiguity shall be resolved in favor of the Tax Commissioner of the Ohio Department of Taxation, the Director of the Ohio Department of Development, and the Director of the Ohio Department of Jobs and Family Services.

I understand that by signing this application, I grant the Ohio Department of Development, or its authorized providers, access to my bank, employment, public assistance, utility company or other records needed for verification and evaluation of services. I further grant Ohio Department of Development, or its authorized providers, access to any information that I have provided to any other state agency, including but not limited to income information regarding requests for public assistance. I understand that filling out this application does not guarantee that my household will receive assistance. If I am or become a PIPP customer I understand that I may be included in a group for which electric service is purchased in common. I understand that any authorized provider may rescind an approved payment if information is acquired which determines that my household is not eligible for services according to the rules of each program. I understand that I have the right to appeal. I certify that the information I have provided in this application is, to the best of my knowledge, a true, accurate and complete disclosure of the requested information. I understand that I may be held civilly and criminally liable under federal and state laws for knowingly making false or fraudulent statements.

I declare under penalty of perjury the information submitted in this application is true and correct.

The State of Ohio is an Equal Opportunity Employer and Provider of ADA Services.

X Sign Here ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Application Date _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PLEASE SIGN AND MAIL APPLICATION TO:

Office of Community Assistance, Home Energy Assistance Program

P.O. Box 1240, 43216 Columbus, Ohio

Date Printed – June 2025

When determining households up to eight members for HEAP, SCP, and WCP, 175% of the Federal Poverty Guidelines (FPG) is used. For HEAP, SCP, and WCP households over eight members, 60% State Median Income (SMI) is used. PIPP and EPP for all household sizes is 175% of the FPG. When determining 200% of the FPG for HWAP, households with more than eight members must add $11,000 for each additional member.

JULY 2025 – MAY 2026 Income Guidelines Size of Household

1 $27,387 $31,300 2 $37,012 $42,300 3 $46,637 $53,300 4 $56,262 $64,300 5 $65,887 $75,300 6 $75,512 $86,300 7 $85,137 $97,300 8 $94,762 $108,300

(175%) (For PIPP, EPP, HEAP, WCP and SCP)

(200%) (For HWAP)

How can I check the status of my application?

To check the status of your application, please visit energyhelp.ohio.gov and create an account.

Please note: Applications are processed in the order received and may take up to 12 weeks from the date of your signed application.

HEAP benefits may be applied to your utility bill starting January 2026.

IMPORTANT: The HEAP Program runs from July 1, 2025 – May 30, 2026. Applications dated June 1, 2026 – June 30, 2026, will be processed for PIPP, EPP and/or HWAP only. Customers seeking HEAP must submit a new application starting July 1.

If you have questions, please contact your local energy assistance provider or send us a message by visiting energyhelp.ohio.gov and clicking “contact us.”

Page 4 of 6 u Page 5 of 6 u Page 6 of 6 n

Total Household Eligible Income Section* Please add the total income received for each adult household member then subtract the total household deductions.

Total Household Income (add amounts from Household Income Section on pages 3 & 4)

Past 30 Days

Past 12 Months

Total Household Deductions

(from Household Deductions Section on page 5)

Past 30 Days

Past 12 Months

Total Eligible Income Total Household Income minus Total Household Deductions above

Total Household Income minus Total Household Deductions above

If applicable, please explain the difference in the past 30 days income from the past 12 months’ income.

Please note: Income from child support received and VA disabilities are not countable income. For a complete list of excluded income, please visit energyhelp.ohio.gov. Documentation of excluded income may be required to complete your application.

Utility Information Section* Natural Gas

Propane or Bottle Gas (L.P. Gas)

Fuel Oil or Kerosene

Coal, Wood, or Pellets

Electric (Includes baseboards)

Other

Yes No Yes No

Yes No Yes No

Please provide your electric utility provider information (if not provided above):

Electric Company/Vendor Account Number Costs included in rent? Shared Meter?

Account Holder’s First Name Account Holder’s Last Name Relationship to Primary Client

If you are currently enrolled in PIPP, do you wish to reverify on this account?

Do you wish to enroll in PIPP and do you have a regulated utility provider?

Yes No

Yes No

Yes No

Yes No

Household Members and Income Section – Continued Fill out the table below for additional household members.

Print additional pages, as needed, for other household members with income.

Household Deductions Section* Total Household Income Deductions (Choose all that apply)

Total Deductions for the past 30 Days

Total Deductions for the past 12 Months

Please note: Documentation of deduction(s) is required.

Attorney fees for estate or trust settlements

Child Support paid-out

Health Insurance Premiums

Health Care Spending Accounts

Medicaid Spend Down (deductibles)

Medicare Premiums

Prescription Plans

Reimbursement for work expenses

Self-employment IRS allowable business expenses

Short- and long-term disability

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† † Other Earned Income† †

Social Security

Supplemental Security (SSI)

Social Security Disability Insurance

(SSDI)

Pension (Private and VA)

Widow/Widower’s Benefit

Alimony

Black Lung Pension

Lump Sum payout from these sources

Wages

Active Military Pay

Unemployment

Utility Assistance

Workers’ Compensation

Employment Disability Payout

Strike Benefit

Cash withdrawn from IRAs / Annuities / Other Investments

Interest Income

Lump Sum Payouts (Estate and Trust Settlements / Divorce Settlements / Insurance Payout / Lottery Winnings)

Dividends

Capital Gains

Other

Self-employment (includes owning own business, babysitting, home party sales, odd jobs, Ohio Electronic Child Care, etc.)

Seasonal employment (includes teachers, construction workers, etc.)

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

† These categories MUST provide 12 months of income documentation

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† Other Earned Income†

Social Security

Supplemental Security (SSI)

Social Security Disability Insurance

(SSDI)

Pension (Private and VA)

Widow/Widower’s Benefit

Alimony

Black Lung Pension

Lump Sum payout from these sources

Wages

Active Military Pay

Unemployment

Utility Assistance

Workers’ Compensation

Employment Disability Payout

Strike Benefit

Cash withdrawn from IRAs / Annuities / Other Investments

Interest Income

Lump Sum Payouts (Estate and Trust Settlements / Divorce Settlements / Insurance Payout / Lottery Winnings)

Dividends

Capital Gains

Other

Self-employment (includes owning own business, babysitting, home party sales, odd jobs, Ohio Electronic Child Care, etc.)

Seasonal employment (includes teachers, construction workers, etc.)

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Gender Ethnicity

Race U.S. Citizen / Legal Resident (Qualified Alien)*

Yes No

American Indian/Alaskan Native

American Indian/Alaskan Native & Black/African American

American Indian/Alaskan Native & White

Asian

Asian/White

Black/African American

Black/African American/White

Native Hawaiian/ Other Pacific Islander

Other Multi-Race

White

Yes No Female Male Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

† These categories MUST provide 12 months of income documentation

Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Gender Ethnicity

Race U.S. Citizen / Legal Resident (Qualified Alien)*

Yes No

American Indian/Alaskan Native

American Indian/Alaskan Native & Black/African American

American Indian/Alaskan Native & White

Asian

Asian/White

Black/African American

Black/African American/White

Native Hawaiian/ Other Pacific Islander

Other Multi-Race

White

Yes No Female Male Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

Accepted Citizenship Documentation (DO NOT SEND ORIGINAL DOCUMENTS) Proof of U.S. Citizenship Proof of Legal Resident/Qualified Alien

1. Birth Certificate/Hospital Birth Records/Birth Registration Card

2. Baptismal Records (Only when place and date of birth is shown)

3. Indian Census Record

4. Military Service Record

5. U.S. Passport

6. Verified Citizenship for Ohio Works First (OWF) Program

7. Voter Registration Cards

8. Social Security Cards (Social Security Cards administered by Social Security Administration that are valid for work authorization status only will not be accepted for citizenship verification)

1. Naturalization Papers/Certifications of Citizenship

2. INS ID Card

3. Alien Registration Cards/Re-entry permits

4. INS Form I-151, IR1-9, or I-551 (Form I-151 will not be valid after August 1, 1993)

5. INS Form I-94 if annotated with either: a) Sections 203(a)(7), 207, 208, 212(d) (5), 243(h), or 241(b)(3) of the Immigration and Nationality Act: or b) One or a combination of the following terms: Refugee, Parolee, or Asylee

6. Permanent Visa INS Form G-641, “Application for verification of Information from INS Records,” when annotated at bottom by INS representative as lawful admission for humanitarian reasons

7. Documentation that alien is classified pursuant to Sections: 101(a)(2), 203(a), 204(a)(1)(a), 207, 208, 212(d)(5), 241(b)(3), 243(h), or 244(a)(3), of the Immigration and Nationality Act

8. Court order stating deportation has been withheld pursuant to Section 241(b)

(3) or 243(h) or of the Immigration and Nationality Act

9. INS Form I-688

Accepted Proof of Income Fixed Income

Earned Employment Income

Supplemental Income

Other Sources of Income Other Earned Income

Award/Benefit letter

Payment printout/ statement from issuing agency

Copy of check or bank statement including deposit

Most recent filed IRS Form 1040 or Tax Transcript

Most recent IRS Form 1099

All pay stubs received 30 days from the date of the application that include gross and year-to-date amounts received (including active military pay)

Completed and signed Employment Verification Form*

Payroll Printout

Most current pay statement (Leave and Earning Statement (LES))

Copy of check/award amount letter

ODJFS documents/ eligibility letter with amounts and dates

Most recent IRS Form

Housing Authority Documentation

Pay stubs received within the previous 30 days from the date of the application

Payment printout/ statement from issuing agency

Statement from Financial Institution

Copy of check or bank statement showing deposit

Most recent IRS Form 1099

Pay stubs indicating amount received within the previous 12 months from the date of the application

Self-Employment Income and Expense Form* for the previous 12 months

Most recent filed IRS Form 1040 and Schedules

Most recent IRS Form 1099

Seasonal Employment Verification Form*

*All forms marked with an asterisk can be found at energyhelp.ohio.gov.

Privacy Act Notice DISCLOSURE: The disclosure of Social Security numbers is mandatory to receive HEAP benefits.

AUTHORITY: 45 CFR 96.84 (c); 42 U.S.C. 405(c)(2)(C)(i)

USE: The state will use Social Security numbers in the administration of the Home Energy Assistance Program to verify information supplied on the application to prevent, detect and correct fraud, waste, and abuse. The information is also used to respond to requests for information from agency programs funded by block grants to states for Temporary Assistance for Needy Families or agencies requesting information for child support or to establish paternity. The applicant may be held civilly or criminally liable under federal or state law for knowingly making false or fraudulent statements.

Primary Household Member Personal Information Section* Enter the information completely. Do NOT send originals. PLEASE USE DARK BLUE OR BLACK INK.

Failure to fill out the application completely, provide all the required documentation and sign the application (on the last page) will delay the processing of your application.

Primary Household Member Income Section* Failure to fill out the application completely, provide all the required documentation and sign the application will delay the processing of your application.

Household Members and Income Section If you have additional household members (anyone living in your household at the same address), please complete Household Members and Income Section of the application (this section), on pages 2–4. If you have more than five household members, print an additional household member section page from energyhelp.ohio.gov or pick up another application at your energy assistance provider.

Pl ea se te ar h er e an d ke ep in st ru ct io ns fo r y ou r r ec or ds

First Name* M.I. Last Name*

Social Security Number* U.S. Citizen / Legal Resident (Qualified Alien)* Military Status Date of Birth (MM / DD / YYYY)*

Yes No Active Veteran No Military Service

Disabled* Gender Ethnicity

Race

Non-Cash Benefits

Number of Household Members

Family Type Housing Type Residence Structure

Email Address Phone Number (including area code)

Preferred Method of Contact

Mailing Address (number and street including route)* Apt/Lot/Unit/Floor

City* State* ZIP Code* County*

Is Utility Service Address the Same?*

Current Service Address (if different from above; number and street including route) Apt/Lot/Unit/Floor

City State ZIP Code County

Do You Receive Rental Assistance?* Landlord Organization (if you rent)

Landlord First Name* Landlord Last Name* Landlord Phone Number – Cell and/or Landline (including area code)*

Landlord Mailing Address (number and street including route, Apt/Lot/Unit/Floor)* Landlord E-Mail Address*

City* State* ZIP Code* County*

Page 1 of 6 u Page 2 of 6 u Page 3 of 6 (OVER) u

Date Received

Client Number

American Indian/Alaskan Native

American Indian/Alaskan Native & Black/African American

American Indian/Alaskan Native & White

Asian

Asian/White

Black/African American

Black/African American/White

Native Hawaiian/Other Pacific Islander

Other Multi-Race

White

Yes No

Yes No Female Male Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

Email Postal

Same as above Different (list below)

Single Parent/Male

Single Parent/Female

Two-Parent Household

Single Person

Own

Rent

Mobile Home

Single-Family

Multi-Family Low Rise (3 stories or less)

Multi-Family High Rise (4 stories or more)

Non-related Adults with Children

Multigenerational Household

Other

Supplemental Nutrition Assistance Program (SNAP) / Food Stamps

Affordable Care Act Subsidy

Child Care Voucher

Housing Choice Voucher

HUD-VASH

Permanent Supportive Housing

Women, Infants, and Children (WIC)

Other

Household Members and Income Section – Continued Fill out the table below for all household members. Use additional section (on page 4) as needed for other household members with income.

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† Other Earned Income†

Social Security

Supplemental Security (SSI)

Social Security Disability Insurance

(SSDI)

Pension (Private and VA)

Widow/Widower’s Benefit

Alimony

Black Lung Pension

Lump Sum payout from these sources

Wages

Active Military Pay

Unemployment

Utility Assistance

Workers’ Compensation

Employment Disability Payout

Strike Benefit

Cash withdrawn from IRAs / Annuities / Other Investments

Interest Income

Lump Sum Payouts (Estate and Trust Settlements / Divorce Settlements / Insurance Payout / Lottery Winnings)

Dividends

Capital Gains

Other

Self-employment (includes owning own business, babysitting, home party sales, odd jobs, Ohio Electronic Child Care, etc.)

Seasonal employment (includes teachers, construction workers, etc.)

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† Other Earned Income†

Social Security

Supplemental Security (SSI)

Social Security Disability Insurance

(SSDI)

Pension (Private and VA)

Widow/Widower’s Benefit

Alimony

Black Lung Pension

Lump Sum payout from these sources

Wages

Active Military Pay

Unemployment

Utility Assistance

Workers’ Compensation

Employment Disability Payout

Strike Benefit

Cash withdrawn from IRAs / Annuities / Other Investments

Interest Income

Lump Sum Payouts (Estate and Trust Settlements / Divorce Settlements / Insurance Payout / Lottery Winnings)

Dividends

Capital Gains

Other

Self-employment (includes owning own business, babysitting, home party sales, odd jobs, Ohio Electronic Child Care, etc.)

Seasonal employment (includes teachers, construction workers, etc.)

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† Other Earned Income†

Social Security

Supplemental Security (SSI)

Social Security Disability Insurance

(SSDI)

Pension (Private and VA)

Widow/Widower’s Benefit

Alimony

Black Lung Pension

Lump Sum payout from these sources

Wages

Active Military Pay

Unemployment

Utility Assistance

Workers’ Compensation

Employment Disability Payout

Strike Benefit

Cash withdrawn from IRAs / Annuities / Other Investments

Interest Income

Lump Sum Payouts (Estate and Trust Settlements / Divorce Settlements / Insurance Payout / Lottery Winnings)

Dividends

Capital Gains

Other

Self-employment (includes owning own business, babysitting, home party sales, odd jobs, Ohio Electronic Child Care, etc.)

Seasonal-employment (includes teachers, construction workers, etc.)

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† † Other Earned Income†

Social Security

Supplemental Security (SSI)

Social Security Disability Insurance

(SSDI)

Pension (Private and VA)

Widow/Widower’s Benefit

Alimony

Black Lung Pension

Lump Sum payout from these sources

Wages

Active Military Pay

Unemployment

Utility Assistance

Workers’ Compensation

Employment Disability Payout

Strike Benefit

Cash withdrawn from IRAs / Annuities / Other Investments

Interest Income

Lump Sum Payouts (Estate and Trust Settlements / Divorce Settlements / Insurance Payout / Lottery Winnings)

Dividends

Capital Gains

Other

Self-employment (includes owning own business, babysitting, home party sales, odd jobs, Ohio Electronic Child Care, etc.)

Seasonal employment (includes teachers, construction workers, etc.)

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 30 Days

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

Gross Income for the Past 12 Months

† These categories MUST provide 12 months of income documentation

† These categories MUST provide 12 months of income documentation

† These categories MUST provide 12 months of income documentation

† These categories MUST provide 12 months of income documentation

* Indicates information required in order to process your application.

Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Gender Ethnicity

Race U.S. Citizen / Legal Resident (Qualified Alien)*

Yes No

American Indian/Alaskan Native

American Indian/Alaskan Native & Black/African American

American Indian/Alaskan Native & White

Asian

Asian/White

Black/African American

Black/African American/White

Native Hawaiian/ Other Pacific Islander

Other Multi-Race

White

Yes No Female Male Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Gender Ethnicity

Race U.S. Citizen / Legal Resident (Qualified Alien)*

Yes No

American Indian/Alaskan Native

American Indian/Alaskan Native & Black/African American

American Indian/Alaskan Native & White

Asian

Asian/White

Black/African American

Black/African American/White

Native Hawaiian/ Other Pacific Islander

Other Multi-Race

White

Yes No Female Male Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Gender Ethnicity

Race U.S. Citizen / Legal Resident (Qualified Alien)*

Yes No

American Indian/Alaskan Native

American Indian/Alaskan Native & Black/African American

American Indian/Alaskan Native & White

Asian

Asian/White

Black/African American

Black/African American/White

Native Hawaiian/ Other Pacific Islander

Other Multi-Race

White

Yes No Female Male Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

For Office Use Only

Missing information may delay processing of your application.