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LIHEAP Application

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Step 1 of 5

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Appt Validation
Your LIHEAP appointment for has been received.
You MUST make an appointment before completing the LIHEAP Application.
NOTE: Appointment links are ONLY active 8:00am - 11:59pm weekdays.
Manatee County
Current scheduling: 8:00am-10:30am
Monday-Friday
Hardee County
Current scheduling: 8:00am-12:30pm
on the 2nd and 4th Wednesday of each month
You MUST click "NEXT" to continue the LIHEAP process.
For Staff Use Only
Appt Location*

Name*
First Last
Do you have a SSN?
Last 4 of SSN*
Please enter a number from 0000 to 9999.
Applicant Date of Birth*
MM
DD
YYYY
Please Enter Your Address Below:*
Street Address Address Line 2 City State ZIP Code
Home Phone
Cell Phone
Work Phone
Email
Gender*
Disabled?*
Veteran?*
Insurance*
Primary Language*
Second Language
Housing*
Applicant Marital Status*
Education Level
Ethnicity*
Race (select all that apply)
- Asian
- Black/African American
- Native Hawaiian/Pacific Islander
- US Indian/Alaskan Native
- White
- Other

INCOME:
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
HOUSEHOLD INFORMATION:
Other people who live in your household
How many other people live in your home?
Please enter a number from 0 to 9.
Household Member 1:
Name
First Last
Does this person have a SSN?
Person 1 - Last 4 of SSN
Please enter a number from 0001 to 9999.
Date of Birth
MM
DD
YYYY
Relationship to Applicant
Gender
Disabled?
Veteran?
Marital Status
Education Level
Ethnicity
Insurance
Primary Language
Second Language
Race (select all that apply)
- Asian
- Black/African American
- Native Hawaiian/Pacific Islander
- US Indian/Alaskan Native
- White
- Other
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Household Member 2:
Name
First Last
Does this person have a SSN?
Person 2 - Last 4 of SSN
Please enter a number from 0001 to 9999.
Date of Birth
MM
DD
YYYY
Relationship to Applicant
Gender
Disabled?
Veteran?
Marital Status
Education Level
Ethnicity
Insurance
Primary Language
Second Language
Race (select all that apply)
- Asian
- Black/African American
- Native Hawaiian/Pacific Islander
- US Indian/Alaskan Native
- White
- Other
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Household Member 3:
Name
First Last
Does this person have a SSN?
Person 3 - Last 4 of SSN
Please enter a number from 0001 to 9999.
Date of Birth
MM
DD
YYYY
Relationship to Applicant
Gender
Disabled?
Veteran?
Marital Status
Education Level*
Ethnicity
Insurance
Primary Language
Second Language
Race (select all that apply)
- Asian
- Black/African American
- Native Hawaiian/Pacific Islander
- US Indian/Alaskan Native
- White
- Other
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Household Member 4:
Name
First Last
Does this person have a SSN?
Person 4 - Last 4 of SSN
Please enter a number from 0001 to 9999.
Date of Birth
MM
DD
YYYY
Relationship to Applicant
Gender
Disabled?
Veteran?
Marital Status
Education Level*
Ethnicity
Insurance
Primary Language
Second Language
Race (select all that apply)
- Asian
- Black/African American
- Native Hawaiian/Pacific Islander
- US Indian/Alaskan Native
- White
- Other
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Household Member 5:
Name
First Last
Does this person have a SSN?
Person 5 - Last 4 of SSN
Please enter a number from 0001 to 9999.
Date of Birth
MM
DD
YYYY
Relationship to Applicant
Gender
Disabled?
Veteran?
Marital Status
Education Level*
Ethnicity
Insurance
Primary Language
Second Language
Race (select all that apply)
- Asian
- Black/African American
- Native Hawaiian/Pacific Islander
- US Indian/Alaskan Native
- White
- Other
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Household Member 6:
Name
First Last
Does this person have a SSN?
Person 6 - Last 4 of SSN
Please enter a number from 0001 to 9999.
Date of Birth
Date Format: MM slash DD slash YYYY
Relationship to Applicant
Gender
Disabled?
Veteran?
Marital Status
Education Level*
Ethnicity
Insurance
Primary Language
Second Language
Race (select all that apply)
- Asian
- Black/African American
- Native Hawaiian/Pacific Islander
- US Indian/Alaskan Native
- White
- Other
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency
Income Source
Income Amount
Frequency

Prior LIHEAP Services:
Have you received LIHEAP services from Step Up Suncoast in the last 12 months?*
- Yes
- No
Month
Please enter a number from 1 to 12.
Year
Please enter a number from 00 to 2100.
Energy/Electric Provider & Current Bill Information:
Provider*
Account Number
Customer Name on Bill
What is your relationship to the customer's name on the bill?
Current Amount Owed
Current Energy Bill Status:
Status of Energy Bill
Date payment is due
Date Format: MM slash DD slash YYYY
Additional Information:
Do you receive utility reimbursement through your public housing?*
If yes, how much?
Are you or anyone in your home a member of an Indian Tribe?
Which member of the household?
Name of Tribe:
If your monthly income is less than $600, please explain how you are maintaining your household:

*
- I have given true, correct and complete information and I will give proof of things I report. I give Step Up Suncoast permission to verify the information and contact my energy provider and to provide information. I know that Step Up Suncoast may use computers to check the information on this form.
*
- I give Step Up Suncoast permission to make benefit payments directly to my energy proivder.
*
- I understand that after providing required documentation, Step Up Suncoast will approve or deny my application within 48 hours or 18 hours if my situation is life threatening. I understand I have three working days to return missing information after my appointment or my file will be denied as incomplete.
*
- I understand that if funding is limited, Step Up Suncoast will give priority to households with vulnerable people including the elderly, disabled or children less than five (5) years of age. I understand that if funding is limited, my application may be prescreened and I will be notified if I do not meet the priority.
*
- I understand that making false statements or hiding information could mean state and federal penalties and denial of current and future assistance.
*
- I understand that if I receive benefits I am not eligible for, then I will have to pay Step Up Suncoast back for those benefits even if the error was caused by Step Up Suncoast.
*
- I understand that if my application is denied, I may reapply at a later time.
*
- I understand that I have the right to an appeal if services are denied or reduced, the benefit amount is in question, or if your application is not acted upon with reasonable promptness.
*
- I understand that the social security numbers required for this application will be used for identification purposes only and will be treated confidentially.
*
- I affirm under penalty of perjury that the statements made about persons in my home, income, and all other information I have given is true and correct.
- I would like to receive messages from Step Up Suncoast via email and text message
Electronic Signature:
Name*
To confirm that everything you have entered is true and correct, please retype your name and last 4 numbers of your SSN.
Name
To confirm that everything you have entered is true and correct, please retype your name and last 4 numbers of your SSN.
Last 4 of SSN
Leave blank if no SSN
Please enter a number from 0000 to 9999.
For Office Use Only:


Client Signature	____________________________________________	Date	_____________________________

Client Services Rep.	____________________________________________	Date	_____________________________

Reviewer	____________________________________________	Date	_____________________________

Confirmation #
Appt Link
Appt Time
Form Link
Form Status
Language

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Hours of Operations

Administration

Monday-Friday
8:00am - 5:00pm

Locations

Manatee County

6428 Parkland Drive

Sarasota, FL 34243

Hardee & DeSoto County

202 North 6th Ave

Wauchula, FL 33873

Phones & Faxes

Phone

941-827-2887 (Main)

941-827-0188 (Programs)

941-750-6667 (HeadStart)

863-261-8604 (Hardee/DeSoto)

855-827-5081 (Toll Free)

Fax

941-827-3001 (Main)

941-827-0193 (Programs)

941-746-7374 (HeadStart)

STOP!

You have not completed the LIHEAP process.

To continue, please click any area on the screen.

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Step 1 of 5

You MUST make an appointment before completing the LIHEAP Application.

Manatee County

Hardee County

INCOME:

HOUSEHOLD INFORMATION:

Household Member 1:

Household Member 2:

Household Member 3:

Household Member 4:

Household Member 5:

Household Member 6:

Prior LIHEAP Services:

Energy/Electric Provider & Current Bill Information:

Current Energy Bill Status:

Additional Information:

Electronic Signature:

For Office Use Only: