Your Income (Do not include  other Household Members)

Household Members

Household Member Income

Which utility company do you want to receive your LIHWAP grant? Write their name and address, and your account information.

Please upload the following documents:

1. My signature on this application gives my permission to the Department of Human Services or its authorized agent to: (a) check any information I give with a third party about where I live, my jobs,income, resources, water supply, and water supplier; (b) share information with my water supplier and receive information from my water supplier to allow DHS to obtain a record of my annual water consumption, cost and billing information for purposes of program evaluation, operation, or reporting; and (c) complete any survey in connection with water assistance.

2. Furnishing this information (including your SSN) is voluntary; however, failure to furnish the requested information may delay or prevent the completion of your application or delay or prevent your ability to receive benefits. If you fail to provide household SSNs or fail to complete the information below, you may be ineligible for benefits 

3. I authorize the release of LIHWAP eligibility information to and from my water suppliers and allow them to seek assistance for which I may be eligible. The assistance may include LIHWAP Cash or Crisis.

4. I understand I have the right to appeal any decision or undue delay in decision which I consider improper regarding this application.

5. I affirm that Pennsylvania is my legal residence.

6. I understand any Social Security number(s) given will be used in the administration of this program, including accessing identity and income data from other programs.

7. I understand that I will be sent a notice of eligibility or ineligibility and, if eligible, the notice will state the amount of my benefit.

8. I further understand that if my household is eligible for a LIHWAP cash or crisis benefit, it must be sent directly to my utility company. This benefit will never be sent directly to my landlord.

9. I certify that, subject to penalties provided by law, the information I gave is true, correct and complete to the best of my knowledge.

10. I know that if I give false information, I can be penalized by fine and/or imprisonment.

11. I understand by signing this application, I may not qualify because LIHWAP money has run out.

12. If I did not understand something or was confused by something, I spoke to the county assistance office (or other person or agency).

Privacy Act Notice; Authority: 42 U.S.C. § 405(c)(2)(C)(i) authorizes the collection of this information.Purpose: The Department of Human Services (“DHS”) will use this information to identify and verify income of applicant(s).Routine Uses: The information will be used by and disclosed to DHS personnel and contractors or other agents who need the information for LIHWAP administration. Additionally, DHS may share the information with other government agencies or in reports to legislative representatives as required by federal or Pennsylvania law.