LIHEAP Application

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Step 1 of 5

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Appt Validation
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
Your LIHEAP appointment for has been received.
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*
Month
Day
Year
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

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
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:


Client Signature	____________________________________________	Date	_____________________________

Client Services Rep.	____________________________________________	Date	_____________________________

Reviewer	____________________________________________	Date	_____________________________

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:

Hours of Operations

Administration

Locations

Phones & Faxes

Phone

Fax

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:

Stay in touch with Step Up Suncoast

Hours of Operations

Administration

Locations

Phones & Faxes

Phone

Fax

STOP!