LDSS-3421 (Rev.

5/22)

HOME ENERGY ASSISTANCE PROGRAM APPLICATION

If you are blind or seriously visually impaired and need this application in an
alternative format, you may request one from your social services district. For
additional information regarding the types of formats available and how you can
request an application in an alternative format, see the attached instructions or
visit www.otda.ny.gov.

If you are blind or seriously visually impaired, would you like to receive written
notices in an alternative format? ____ Yes ____ No

If Yes, check the type of format you would like:

___ Large Print ___ Data CD ___ Audio CD
___ Braille, if you assert that none of the other alternative formats will be
equally effective for you.

If you require another accommodation, please contact your social services

district.
LDSS-3421 (Rev. 5/22)

HOME ENERGY ASSISTANCE PROGRAM APPLICATION

PLEASE READ THE INSTRUCTIONS ATTACHED TO THE BACK OF THE APPLICATION. ANSWER ALL QUESTIONS. DO NOT WRITE IN THE SHADED
AREAS. PLEASE PRINT CLEARLY AND SIGN THE FORM ON PAGE 5. COMPLETE THE WHITE BOXES BELOW IN BLUE OR BLACK INK.
AGENCY USE ONLY
DSS OFA/ALTERNATE CERTIFIER

CONTACT THE AGENCY ABOVE IF YOU NEED HELP DATE RECEIVED DATE RECEIVED
AGENCY USE ONLY
APPLICATION DATE OFFICE UNIT ID WORKER ID CASE CASE NUMBER REGISTRY NUMBER VERS.
TYPE

CASE NAME  REGULAR  HEATING EQPT  COOLING

 EMERGENCY  CLEAN & TUNE  OTHER___________
SECTION 1: HOUSEHOLD COMPOSITION
APPLICANT INFORMATION
FIRST NAME MI LAST NAME

OTHER NAMES BY WHICH I HAVE BEEN KNOWN ARE: OTHER NAME OTHER NAME
CURRENT STREET ADDRESS APT. # CITY

STATE ZIP CODE COUNTY LENGTH OF TIME AT THIS ADDRESS? YEARS__________ MONTHS__________

DAYTIME PHONE NUMBER WHERE I CAN BE REACHED (Area Code + Phone No.) BEST TIME TO CALL IF AN INTERVIEW IS NEEDED, I WOULD LIKE A:
 Phone Interview  In Person Interview
What language do you prefer to speak?
What language do you prefer to read?
Will you require a free interpreter?
MY MAILING ADDRESS (IF DIFFERENT FROM ABOVE) IS:
ADDRESS APT. # CITY COUNTY STATE ZIP CODE

HAVE YOU EVER APPLIED FOR HEAP?  YES  NO IF YES, ENTER DATE OF MOST RECENT APPLICATION 
LIST EVERYONE INCLUDING YOURSELF WHO CURRENTLY LIVES IN THE SAME HOUSE (If no one else, write NONE UNDER YOUR NAME):
GENDER IDENTITY (Optional) CITIZEN /
DATE OF SEX Male, Female, Non-Binary, X,
BIRTH RELATION SOCIAL SECURITY NATIONAL
CD LN FIRST NAME MI LAST NAME Transgender, Prefer not to say, OR
MO. DAY YR. M/F TO ME NUMBER
Different Identity (Please QUALIFIED ALIEN
describe)

1 01 SELF
 YES  NO

1 02  YES  NO

1 03  YES  NO

1 04  YES  NO

1 05  YES  NO

1 06  YES  NO

If there are more members in your household, please attach a separate sheet of paper. Total Number in Household: ___________________

Is anyone in your household blind or disabled?  YES  NO If yes, who? ___________________________________________________________

DO YOU OR DOES ANYONE LIVING AT YOUR ADDRESS GET OR HAVE RECENTLY APPLIED FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)?
 YES  NO If yes, who? ___________________________________________ CASE NUMBER __________________________

DO YOU OR DOES ANYONE LIVING AT YOUR ADDRESS GET OR HAVE RECENTLY APPLIED FOR TEMPORARY ASSISTANCE?
 YES  NO If yes, who? ___________________________________________ CASE NUMBER __________________________

IS ANYONE IN YOUR HOUSEHOLD A VETERAN?  YES  NO If yes, who? __________________________________________________________

LDSS-3421 (Rev. 5/22) PAGE 2

SECTION 2: HOUSING – CHECK () ONE BOX ONLY

HOMEOWNER RENTER
Single Family House or Mobile Home Private House, Apartment or Mobile Home
Multi-Family House; List Number of Units ____
Co-op/Condo Owner SUBSIDIZED RENT
Life Estate/Use Private Subsidized Housing
OTHER Public Housing Project or Senior Housing
I live with someone else and share expenses Public Subsidized Housing
I pay for a room
I pay room and board Do you receive a HUD utility allowance?
Permanent hotel/motel Yes If yes, how much $___________ No
Other living situation _______________________________

MY MONTHLY RENT OR MORTGAGE PAYMENT IS:

$ ________________________ NONE

IF APPLICABLE, THE NAME OF THE APARTMENT BUILDING OR HOUSING PROJECT I LIVE IN IS:
___________________________________________________________________________________

DO YOU OR DOES ANYONE IN YOUR HOUSEHOLD RECEIVE A SENIOR CITIZEN RENT INCREASE EXEMPTION (SCRIE)?
YES NO

SECTION 3: HEAT AND UTILITY INFORMATION

1. DO YOU PAY SEPARATELY FOR HEAT? Yes- Complete information below No
My main source of heat is
Natural Gas Fuel Oil Electric Coal or Corn
Wood/Wood Pellets Kerosene Propane or Bottle Gas Other _________________

My fuel tank is: Individual Tank Metered Tank

Is the heating bill in your name? YES NO

If No, name on the bill: _____________________________________ Relationship to you: ________________________

Are you directly responsible to pay the bill? YES NO

Your heating company’s name is: ______________________________________________________________________________

Your Heating Company’s Address: _____________________________________________________________________________

_____________________________________________________________________________

Your heating account number is: __________________________________________________________

2. DO YOU PAY A SEPARATE ELECTRIC BILL FOR UTILITIES OTHER THAN HEAT?

YES – Complete information below NO

If yes, is the electric bill in your name? YES NO If No, name on the bill _________________________________

Your electric account number (if you have one) is: ___________________________________________________

Your utility company’s name is: ___________________________________________________

Is electric necessary to run the furnace? YES NO

Is electricity necessary to operate the thermostat in your apartment? YES NO

3. ARE BOTH HEAT AND ELECTRIC INCLUDED IN YOUR RENT? YES NO

LDSS-3421 (Rev. 5/22) PAGE 3
SECTION 4: HOUSEHOLD INCOME
REPORT ANY INCOME FOR ALL HOUSEHOLD MEMBERS. ALL AMOUNTS MUST BE REPORTED AS GROSS
MONTHLY INCOME BEFORE ANY DEDUCTIONS. ATTACH ADDITIONAL SHEETS IF NECESSARY.
CHECK YES OR TYPE OF INCOME IF YES, GIVE AMOUNT ADDITIONAL INFORMATION WHO
NO FOR EACH (√) RECEIVES?
GROSS MONTHLY AMOUNT Indicate amount you pay for :
SOCIAL SECURITY AMOUNT
Medicare
$ Part B:
 YES  NO BEFORE MEDICARE PART B & D
Medicare
Part D:
GROSS MONTHLY AMOUNT Indicate amount you pay for :
SOCIAL SECURITY DISABILITY AMOUNT
Medicare
$ Part B:
 YES  NO BEFORE MEDICARE PART B & D
Medicare
Part D:
GROSS MONTHLY AMOUNT
SUPPLEMENTAL SECURITY INCOME (SSI) $
 YES  NO
 WEEKLY $ Employer
 BI-WEEKLY $
 YES  NO WAGES  MONTHLY $
SUBMIT WAGE STUBS FOR THE PAST 4 WEEKS.  SEMI-MONTHLY
 WEEKLY $ Employer
Note: Gross Weekly amounts are multiplied by  BI-WEEKLY $
4.333333 to calculate the monthly amount.  MONTHLY $
 SEMI-MONTHLY
Gross Bi-Weekly amounts are multiplied by Employer
2.166666 to calculate the monthly amount.  WEEKLY $
 BI-WEEKLY $
 MONTHLY $
 SEMI-MONTHLY
 WEEKLY $ Employer
 BI-WEEKLY $
 MONTHLY $
 SEMI-MONTHLY
PENSION/RETIREMENT Private and/or government GROSS MONTHLY AMOUNT Source of Pension
 YES  NO $
GROSS MONTHLY AMOUNT
VETERAN’S BENEFITS $
 YES  NO
GROSS WEEKLY AMOUNT Source
DISABILITY private or NYS $
 YES  NO
GROSS MONTHLY AMOUNT Name of Contributor
CONTRIBUTION from someone outside the household $
 YES  NO
GROSS WEEKLY AMOUNT Source
CHILD SUPPORT $
 YES  NO
ALIMONY/SPOUSAL SUPPORT including payments for GROSS MONTHLY AMOUNT Source
 YES  NO mortgage, utility bills, etc. $
GROSS MONTHLY AMOUNT Type of Rental
RENTAL INCOME apartment, garage, land, etc. $
 YES  NO
GROSS MONTHLY AMOUNT Name of Room/Boarder
ROOM/BOARD (received) etc. $
 YES  NO
GROSS WEEKLY AMOUNT
WORKER’S COMPENSATION $
 YES  NO
GROSS WEEKLY AMOUNT Start Date:
UNEMPLOYMENT BENEFITS $
 YES  NO
End Date:

Income from savings, checking, CDs, money market

 YES  NO accounts, stocks, bonds, securities. IRA, annuity, and ENTER INFORMATION ON NEXT PAGE
401K distributions.

AMOUNT Source
IS THERE ANY OTHER INCOME FROM ANY OTHER $
WHO RECEIVES
 YES  NO
SOURCE? ATTACH EXPLANATION

SELF-EMPLOYMENT INCOME______________________
TYPE OF BUSINESS ______________________________
 YES  NO If yes, you may choose to have your self- employment income calculated based on your filed federal tax return for
the current year or prior tax year if you have not yet filed for the current year, including all applicable schedules or
based on the three (3) months prior to your application. Please choose one method:
 Filed Federal Tax Return  Three Months
 LDSS-3421 (Rev. 5/22) PAGE 4
IS THERE ANYONE IN YOUR HOUSEHOLD AGE 18 OR OLDER WHO DOES NOT HAVE ANY INCOME FROM ANY SOURCE?
 YES, list members with no income:  NO

IS THERE ANYONE IN YOUR HOUSEHOLD WHO IS A FULL-TIME DEPENDENT HIGH SCHOOL OR COLLEGE STUDENT?
 YES, list member(s):  NO

INTEREST AND INVESTMENT INCOME

LIST EACH ACCOUNT SEPARATELY. ATTACH ADDITIONAL SHEETS IF AMOUNT RECEIVED SOURCE
NECESSARY. YEAR-TO-DATE

INTEREST from savings, checking, CDs, money market accounts, etc. $ Name of Bank
INTEREST from savings, checking, CDs, money market accounts, etc. $ Name of Bank
INTEREST from savings, checking, CDs, money market accounts, etc. $ Name of Bank
INTEREST from savings, checking, CDs, money market accounts, etc. $ Name of Bank
DIVIDENDS from stocks, bonds, securities, etc. $ Source of Dividends
DIVIDENDS from stocks, bonds, securities, etc. $ Source of Dividends
DIVIDENDS from stocks, bonds, securities, etc. $ Source of Dividends
DIVIDENDS from stocks, bonds, securities, etc. $ Source of Dividends
DISTRIBUTIONS from IRA, 401K, annuity, etc. $ Source of Distributions
DISTRIBUTIONS from IRA, 401K, annuity, etc. $ Source of Distributions
DISTRIBUTIONS from IRA, 401K, annuity, etc. $ Source of Distributions

AUTHORIZED REPRESENTATIVE

You can designate someone who knows your household circumstances to be your authorized representative. Your Authorized
Representative may: complete and file your HEAP application, contact the agency and speak with your worker, have access to
eligibility information in your case file, complete all forms for you, provide documentation, appeal agency decisions. You must still
sign this application. The Authorized Representative designation will remain in effect for the current HEAP season unless revoked
by you. Each HEAP season you will be asked if you want to designate an Authorized Representative.
I would like to designate an authorized representative.  YES - Complete information below  NO

Name of authorized representative: Address and phone number:

PLEASE SIGN APPLICATION ON PAGE 5

LDSS-3421 (Rev 5/22) PAGE 5
SECTION 5: IMPORTANT NOTICES

IMPORTANT NOTICE
YOU SHOULD BE AWARE THAT THERE IS LIMITED MONEY AVAILABLE FOR HEAP BENEFIT PAYMENTS. ONCE AVAILABLE MONEY IS
EXHAUSTED, NO BENEFITS WILL BE ISSUED. THEREFORE, IT IS STRONGLY RECOMMENDED THAT YOU COMPLETE AND SUBMIT YOUR
APPLICATION AS SOON AS POSSIBLE.

PERSONAL PRIVACY LAW - NOTIFICATION TO CLIENTS

The State’s Personal Privacy Protection Law, which took effect September 1, 1984, states that we must tell you what the State will do
with the information you give us about yourself and your family. We use the information to find out if you are eligible for the Home
Energy Assistance Program and, if so, for how much. The section of the Law that gives us the right to collect the information about
you is Section 21 of the Social Services Law. To make sure that you are getting all of the assistance you and your family are legally
entitled to receive, we check with other sources to find out more about the information you have given us. For example:

• We may check to find out if you or anyone in your household were working. We do this by sending your name and Social
Security Number to the State Department of Taxation and Finance, and also to known employers, to tell us whether you
worked and, if so, how much you made.
• We may ask the State to check with the Unemployment Insurance Division to see if you or anyone in your household were
getting unemployment benefits.
• We may check with banks to make sure we know about any income you or anyone in your household may have received.

Besides using the information you give us in this way, the State also uses the information to prepare statistics about all the people
receiving Home Energy Assistance. This information is used for program planning and management. The information is used for
quality control by the State to make sure local districts are doing the best job they can. It is used to verify who your energy supplier is
and to make certain payments to such vendors. Your failure to provide us with the information we need may prevent us from finding
out if you are eligible for assistance and we may then have to deny your application. This information is kept by the Commissioner,
Office of Temporary and Disability Assistance, 40 North Pearl Street, Albany, New York 12243-0001. Do not send your application to
this address. If you or anyone in your household does not have a Social Security Number, a Social Security Number must be applied
for at the U.S. Social Security Administration.

Read the Important Information Below

I swear and/or affirm that the information given on this application and subsequent phone interviews is true and correct. I realize that
any false statements or other misrepresentation knowingly made by me in connection with this application and subsequent requests
for HEAP assistance may result in my being found ineligible for the assistance paid to me or on my behalf. Additionally, any false
statement or misrepresentation knowingly made by me for purposes of obtaining assistance under this program may result in an action
against me which may subject me to civil and/or criminal penalties.

CONSENT
I understand that by signing this application/certification, I consent to any investigation to verify or confirm the information I have given
and other investigation by any authorized government agency in connection with this and any other requests for Home Energy
Assistance Program (HEAP) benefits. I also consent to allow the information provided on this application to be used in referrals to
available weatherization assistance programs and my utility company’s low income programs.
I understand that the State will use my Social Security Number to verify with my home energy vendors the receipt of HEAP. This
authorization also includes permission for any of my home energy vendors (including my utility) to release certain statistical
information, including but not limited to, my electricity usage, electricity cost, fuel consumption, fuel type, annual fuel cost and
payment history to the Office of Temporary and Disability Assistance, the local Social Services District and the United States
Department of Health and Human Services for the purposes of Low Income Home Energy Assistance Program (LIHEAP)
performance measurement.

TO GET HEAP- ALL QUESTIONS MUST BE ANSWERED AND YOUR APPLICATION MUST BE SIGNED AND DATED BELOW.
SIGN HERE: DATE SIGNED

X
NAME OF PERSON, IF ANY, WHO ASSISTED YOU: PHONE NUMBER:
 LDSS-3421 (Rev. 5/22) PAGE 6

AGENCY USE ONLY

APPLICATION TYPE:  Full Documentation  Simplified
Vendor Account Number Vendor Code Vendor Relationship: Current Bill/Vendor Statement
Collateral Contact
IDENTITY OF HOUSEHOLD MEMBERS
LN HOUSEHOLD MEMBER’S NAME DOCUMENTATION
01
02
03
04
05
06

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 REGULAR BENEFIT
expedited regular benefit, vendor contract, etc. SHOW ALL CALCULATIONS (EMERGENCY USE PART B)
Gross Bi-Weekly Income x 2.166666  SEPARATE HEAT (check one)
Gross Weekly Income x 4.333333
 Oil  Kerosene
 LP Gas  Natural Gas
 Wood  Wood Pellets
 Coal/Corn  PSC Electric
 Municipal Electric
 HEAT INCLUDED IN RENT
 Payment to Household
 Payment to Utility

TOTAL INCOME $ Benefit $ ________________

 Application compared to previous information Interview Completed Yes, Date__________ No N/A
 No prior application  No Changes  WMS Inquiry  Changes verified How:_______________________________________
 Pended START: END:  APPROVED  DENIED
CERTIFYING AGENCY

WORKER’S SIGNATURE/DATE

SUPERVISOR’S SIGNATURE/DATE

CONSENT TO WITHDRAW
Only sign here if you want to withdraw your application and not to apply for HEAP.

I CONSENT TO WITHDRAW MY APPLICATION SIGN HERE X_________________________________________________

I UNDERSTAND THAT I MAY REAPPLY FOR HEAP BENEFITS AT ANY TIME DURING THE PERIOD THAT HEAP APPLICATIONS ARE BEING
ACCEPTED
LDSS-3421 (Rev. 5/22) PAGE 7

AGENCY USE ONLY

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.
 Central air conditioning.
 A window or wall air conditioner.
LDSS-3421 (Rev. 5/22) Page 1

NEW YORK STATE HOME ENERGY ASSISTANCE PROGRAM

(HEAP)
APPLICATION INSTRUCTIONS

If you are blind or seriously visually impaired and need an application or these
instructions in an alternative format, you may request them from your social
services district (SSD). The following alternative formats are available:
• Large print;
• Data format (a screen reader-accessible electronic file);
• Audio format (an audio transcription of the instructions or application
questions); and
• Braille, if you assert that none of the alternative formats above will be equally
effective for you.
Applications and instructions are also available for download in large print, data
format and audio format from www.otda.ny.gov. Please note that applications are
available in audio format and Braille solely for informational purposes. In order to
apply, you must submit an application in written, non-alternative format.
If you have any disabilities that prevent you from completing this application and/or
from waiting to be interviewed, please notify your SSD. The SSD will make every
effort to provide a reasonable accommodation to address your needs.
If you require another accommodation, or need other help completing this
application, please contact your SSD. We are committed to assisting and
supporting you in a professional and respectful manner.

IMPORTANT INFORMATION ABOUT PROGRAM DATES

HEAP benefits are only available when the program is open. The opening and closing dates are determined for each
program year. Opening dates for the regular benefit and the emergency benefit components may be different. Information
on the opening and closing dates for this year’s program can be found on the OTDA website at http://www.otda.ny.gov or
by calling our toll-free number at 1-800-342-3009.

ALTERNATIVE FORMATS: Check “YES” or “NO” to indicate whether you are blind or seriously visually impaired and
would like to receive written notices in an alternative format. If "Yes," check the type of format you would like. Alternative
formats are available in large print, data CD, audio CD, or Braille, if you assert that none of the other alternative formats
are equally effective for you. If you require another accommodation, or need other help completing this application,
please contact your SSD.
LDSS-3421 (Rev. 5/22) Page 2
INSTRUCTIONS FOR COMPLETING THE APPLICATION:
Complete all non-shaded areas and answer all questions.
Who should complete and sign the application?
The application should be completed by the person who has primary and direct responsibility for payment of the heating
bill or the primary tenant if heat is included in the rent.
What address should I list?
You must list your current address. This must be your permanent and primary residence.
Why do you need my daytime phone number?
It is important to list a phone number where you can be reached. This will assist in timely processing of your application if
additional information is required.
Will I need an interview?
Some applicants may be required to have an interview. You may choose to have a phone interview or to have an in
person interview. Please indicate your interview preference in the box on page one. Completion of this section does not
mean you will be required to have an interview.
All applications for heating equipment repair or replacement must have an in person interview.
Who should I list as household members?
List everyone who lives in your house, even if they are not related to you or contributing financially to your household.
You may be required to provide proof of identity for all household members. List yourself first on line 1. If you live alone,
write the word “none” on line 2.
Gender Identity
New York State ensures your right to access State benefits and/or services regardless of sex, gender identity or
expression. You must report your sex and the sex of all household members as male or female. The sex you report here
must be the same as what is currently on file with the United States Social Security Administration. The sex you report is
needed to process your application. It will not appear on any benefit card you may receive or any other public-facing
document.
Gender identity is how you perceive yourself and what you call yourself. Your gender identity can be the same as or
different from your sex assigned at birth. Gender identity is not required for this application. If your gender identity, or the
gender identity of anyone in your household, is different than the sex you report for that person and you would like to
provide that person’s gender identity, print “Male”, “Female”, “Non-Binary”, “X”, “Transgender”, “Prefer Not to Say” or
“Different Identity” in the space provided. If you print “Different Identity”, you may choose to describe that person’s gender
identity in the space provided.
Citizen /Alien Information:
In order to receive HEAP, a member of your household, must be a U.S. citizen, Qualified Alien, or U.S non-citizen
national. For additional information on what constitutes a Qualified Alien or U.S. non-citizen national, please contact the
New York State Office of Temporary and Disability Assistance hotline at 1-800-342-3009 or visit the OTDA website at
http://www.otda.ny.gov.
Why do I need to provide Social Security numbers for everyone?
Social Security Numbers must be listed for all household members that have a Social Security Number. The information
is validated with data from the Social Security Administration. If any member does not have a Social Security Number but
has applied for one, write the word “applied” in the Social Security Number box. If a household member does not have a
Social Security Number, write the word “none” in the Social Security Number box. This information may be used to
perform data matches with other state and federal agencies for the purposes of verifying your household’s HEAP
eligibility.
Housing Information
Please check the box that most accurately represents your housing situation.
Heating Situation
Make sure to answer all three (3) questions
LDSS-3421 (Rev. 5/22) Page 3

How should I complete the income section? Will I need to provide proof?
List ALL income for all household members. All amounts should be entered as gross income prior to any deductions.
Deductions include, but are not limited to: income taxes, child support, garnishments, health insurance, and union dues.
You are required to submit documentation of all earned income, including self-employment and rental income. You may
be required to provide proof of other income. Please see page 6 of the application instructions for specific types of
acceptable documentation. Do not submit originals, they will not be returned. Eligibility will be based on your household’s
gross monthly income for the month of application.
Please enter the amount of your Social Security before any deductions for Medicare. List separately the amounts that you
pay for Medicare Part B and/or D. Amounts for Medicare Parts B and D are excluded as income.
Enter only the interest or dividend portions of bank accounts, CDs, stocks, bonds or other investment income. List each
account separately. If you need more space, attach additional sheets. Enter the amount received for the year to date.

What does authorized representative mean?

An authorized representative is a person who may act as your agent for HEAP purposes as listed on the application.
Authorized representative status is for the current program only and you may revoke it at any time during the program by
submitting a statement to your local Social Services District. Since this person may be providing information on your
behalf, it should be someone who knows your circumstances.

Make sure to SIGN and date the application. The application must be signed by the person who has the heating bill in
their name, or who pays the bill if it is in someone else’s name. If heat is included in the rent, the primary tenant must
complete and sign the application.

Motor Voter Registration

Please include the Motor Voter form with your application. Complete this form if you are not registered to vote and you
want to register. This does not affect your HEAP eligibility or benefit amount.

WHAT WILL I NEED TO APPLY?

New applicants will need to include the following documentation along with your application:
• Proof of each household member’s identity
• A valid Social Security Number for each household member that has a Social Security Number
• Proof of residence
• A fuel and/or utility bill if you pay for heat or proof that you pay rent which includes heat
• Documentation of income for all household members
Please see page 6 of the application instructions for specific types of acceptable documentation. In addition, new
applicants will also need to have an interview; and you can choose either a phone interview or an in person interview.
However, if you do choose a phone interview, please include a working phone number and the best time to contact you
for a phone interview on Page 1 of your application.

All applications for heating equipment repair or replacement must be in person with full documentation.

WHERE TO APPLY:
You must apply in the county in which you currently reside. You can apply in person or mail in your application at the
address stamped at the top of the application or can find other local certifiers by checking our website at:
http://www.otda.ny.gov.

MY BENEFITS
You may apply for HEAP online by going to https://www.mybenefits.ny.gov . Once your application for HEAP is
submitted, you can check the status of your application on-line by using your secure online account at
https://www.mybenefits.ny.gov . If your application is approved the amount of the benefit is provided. You may be eligible
for food assistance. Check your eligibility and apply for SNAP at https://www.mybenefits.ny.gov . Additional information
about HEAP and other human services programs can be found at https://www.mybenefits.ny.gov .
LDSS-3421 (Rev. 5/22) Page 4

How will my benefit be paid?

If you are approved and you pay for heat, your payment will be sent to your heating fuel vendor. Your eligibility notice will
include the name of the vendor. If the vendor listed is not correct, notify the local Social Services District immediately. In
some cases, your benefit will be paid to your electric company if heat is included in your rent. Your notice will tell you the
amount of the benefit, how it will be paid, and how it was calculated.

Vendors are not permitted to make deliveries until payment is received or until instructed to do so by the local Social
Services District. Benefits may not be applied to prior deliveries for deliverable fuel sources. If you are in need of fuel
before your vendor has received notification or payment, you must contact your local Social Services District.
Regular HEAP benefits are intended to be a one-time supplement to your annual energy costs and are not intended to
replace your personal payments. You must continue to pay your energy bills.

What is a HEAP Emergency?

• You are out of fuel or have less than ¼ tank of oil, kerosene or propane, or less than a ten (10) day supply of other
deliverable heating fuel.
• Your natural gas or electric heat has been shut off or is scheduled to be shut off.
• Applicant owned heating equipment is not working.

WHAT IF I HAVE AN EMERGENCY?

HEAP benefits can assist with the following emergencies:
• You are out of fuel or have less than ¼ tank of oil, kerosene or propane, or less than a ten (10) day supply of other
deliverable heating fuel.
• Your natural gas or electric heat has been shut off or is scheduled to be shut off.
• Applicant owned heating equipment is not working.
If you have a heating emergency and have applied for, but have not received, your regular benefit, you should contact
your local Social Services District after the program opens. Whenever possible, regular HEAP benefits are used first to
resolve an energy emergency.

DO NOT WAIT UNTIL YOU ARE OUT OF HEATING FUEL OR YOUR GAS/ELECTRIC SERVICE IS OFF TO REQUEST
ASSISTANCE. IF YOUR UTILITY SERVICE IS TERMINATED, YOUR UTILITY COMPANY IS NOT REQUIRED TO
RESTORE YOUR SERVICE EVEN IF YOU ARE ELIGIBLE FOR A HEAP BENEFIT.
FAIR HEARINGS

You have certain rights when filing your HEAP application. You have the right to be told if your application is approved or
denied within thirty (30) business days of the date that the HEAP certifier receives your completed and signed application.

The processing time for applications will not begin until program opening even though you may have received an
application prior to the program opening date as a part of our outreach effort. You have the right to request a conference
and/or a fair hearing if it has been more than thirty (30) business days since the HEAP certifier received your signed and
completed application (or it has been more than thirty (30) business days since program opening if the certifier received
your application prior to program opening) and you have not been told of the eligibility decision.

If you would like a conference, you should ask for one as soon as possible. At the conference, if it is discovered that a
wrong decision was made, or if because of information you provide, the decision has changed our original decision,
corrective action will be taken.

If you would like a conference, contact your local social services district at http://otda.ny.gov/programs/heap/contacts.
This is only for requesting a conference. It is not how you ask for a fair hearing. If you ask for or have a conference, you
are still entitled to a fair hearing.

The Office of Temporary and Disability Assistance (OTDA) policy issuances and manuals are posted on the OTDA
website at otda.ny.gov/legal. These issuances and manuals are available to you or your representative to determine
whether a fair hearing should be requested or to prepare for a fair hearing. In addition, upon request to your local social
services district, specific OTDA policy issuances and manuals will also be available to assist you or your representative.
LDSS-3421 (Rev. 5/22) Page 5

If you live anywhere in New York State, you may request a Fair Hearing by telephone, fax, online, or by writing to the
address below:

Telephone: Statewide toll-free request number is 800-342-3334. Please have the notice, if any, with you when you call.

Fax: your Fair Hearing request to: 518-473-6735

Online: Complete online request form at http://www.otda.ny.gov/oah/

In writing: For notices, fill in the supplied space and send a copy of the notice, or write to:

NYS Office of Temporary and Disability Assistance

Office of Administrative Hearings
P.O. Box 1930
Albany, NY 12201-1930

If you request a fair hearing, NYS will send you a notice of the time and place of the hearing. You have the right to be
represented by legal counsel, a relative, friend, or other person, or to represent yourself. At the hearing, your attorney or
other representative will have the opportunity to present written and oral evidence, as well as the opportunity to question
any persons who appear at the hearing. Also, you have the right to bring witnesses to speak in your favor. You should
bring to the hearing any documents that may be helpful in presenting your case.

If you need free legal assistance, you may be able to obtain such assistance by contacting your local Legal Aid society or
other legal advocate group. You may locate the nearest Legal Aid society or advocate group by checking the yellow
pages under "lawyers".

You have the right to review your case record. Upon your request, you have the right to free copies of documents that
your local Department of Social Services presents into evidence at the fair hearing. Also, upon request, you have the right
to free copies of other documents from your case record that you need for your fair hearing. To request such documents
or to find out how you may review your case record, contact your local social services district at
http://otda.ny.gov/programs/heap/contacts.

If you need someone who speaks Spanish, contact the NYS OTDA Hotline at 1-800-342-3009.

OTHER PROGRAMS YOU MAY BE ELIGIBLE FOR:

WEATHERIZATION ASSISTANCE
You may also be eligible for weatherization assistance programs through NYS Homes and Community Renewal (HCR) or
the New York State Energy Research and Development Authority (NYSERDA). A list of local weatherization sub-grantee
contacts can be found at: http://hcr.ny.gov/weatherization-providers. For more information on available NYSERDA
energy services, visit http://www.nyserda.ny.gov. Your signature on the HEAP application allows a referral and exchange
of information to be made to the weatherization assistance programs on your behalf.

UTILITY LOW INCOME PROGRAM

You may also be eligible to enroll in your utility company’s low-income program. Your signature on the HEAP application
allows a referral to be made to your utility company on your behalf.
LDSS-3421 (Rev. 5/22) Page 6

TYPES OF ACCEPTABLE DOCUMENTATION

RESIDENCE (Where you now live)

• Current rent receipt with name and address of
tenant and landlord or lease with name and address • Utility bill
• Water, sewage, or tax bill • Mortgage payment books/receipts with address
• Homeowner’s/Renter’s Insurance Policy

IDENTITY
You must provide one or more of the following for each person in your household:
• Driver’s License • Validated Social Security Number*
• Photo ID • Adoption Papers
• US Passport or Naturalization Certificate • Hospital or Doctor’s Records
• Birth Certificate or Baptismal Certificate* • School Records
• Statement from another person*

*Two forms of proof required.

SOCIAL SECURITY NUMBER
You must provide valid Social Security Numbers for all household members that have a Social Security Number.
VULNERABILITY
You must provide one of the following for proof of vulnerability for a vulnerable member of your household (children under
6 years of age, adults 60 years of age or older, or anyone with a disability):
• Birth certificate • Passport
• Baptismal certificate with date of birth • Driver’s license
• SSA Award letter • Written statement of eligibility for benefits

HEATING SITUATION
If you pay a fuel or utility bill, provide a copy of your most recent fuel/utility bill or a statement from your vendor.
If you do not pay for heat, provide a current rent receipt with name and address of tenant and landlord, lease with name
and address, or statement from your landlord that indicates heat is included in your rent.
INCOME COPY OF AWARD LETTER OR OFFICIAL
• Pay stubs for the most recent four (4) weeks CORRESPONDANCE FOR THE FOLLOWING:
• If self-employed, business records for the most recent • Social Security/Supplemental Security Income (SSI)
three (3) months or your filed federal tax return for the • Veteran’s Benefits
current year, including all applicable schedules. • Pensions
• Rental income/expenses for previous three (3) months • Worker’s Compensation/Disability
or your filed federal tax return for the current year, • Unemployment Insurance Benefits
including all applicable schedules.
• Child support or alimony/spousal support
• Interest/Bank/Dividend or Tax Statement
• Statement from roomer/boarder

RESOURCES (For emergency benefit applications only)

• Cash • IRA accounts
• Stocks/bonds • Lump sums from sale of property or insurance
• Checking, savings, and/or CD account balances settlements.
• Annuity

Applications for Heating Equipment Repair and Replacement require additional documentation. If you are applying for this
component, you will be given a separate list of documentation you need to provide.
 NYS Agency-Based Voter Registration Form
“If you are not registered to vote where you live now, would you Important!
like to apply to register here today?” Applying to register or declining to register to vote will not affect the
If you do not check amount of assistance that you will be provided by this agency.
If you checked YES, please complete the
YES VOTER REGISTRATION APPLICATION below
any box, you will
If you would like help filling out the voter registration application form,
be considered to
NO because I choose not to register OR have decided not we will help you. The decision whether to seek or accept help is yours.
to register to vote You may fill out the application form in private.
I am already registered at my current address OR
at this time.
I asked for and received a mail registration form Información en español: si le interesa obtener este formulario en español,
llame al 1-800-367-8683

中文資料:若您有興趣索取中文資料表格,請電: 1-800-367-8683
/ /
Signature Date 한국어: 한국어 한국어 양식을 원하시면 1-800-367-8683
으로 전화 하십시오.

যদি আপনি এই ফর্মটি ইংরেজীতে পেতে চান তাহলে 1-800-367-8683

Please Print Name
নম্বরে ফ�োন করুন

VOTER REGISTRATION APPLICATION (instructions on back)

Yes, I need an application for an Absentee Ballot Please print or type in blue or black ink Yes, I would like to be an Election Day worker
A) Will you be 18 years old on or before election day? YES NO
Are you a U.S. citizen?
B) Are you at least 16 years of age and understand that you must be 18
For Board Use Only
years of age on or before election day to vote, and that until you will
1 YES NO 2 be eighteen years of age at the time of such election your registration
will be marked “pending” and you will be unable to cast a ballot in any
If you answered NO, do not complete this form election? YES NO
If you answered NO to both of the prior questions, you cannot register to vote.
Last Name First Name Middle Initial Suffix
3

Address where you live (do not give P.O. box) Apt. No. City/Town/Village Zip Code County
4

Address where you get your mail (if different than above) P.O. Box, Star Route, etc. Post Office Zip Code
5

Date of Birth Gender (optional) Telephone (optional) Email (optional)

6 7 8

The last year you voted Your address was (give house number, street and city) ID Number (Check the applicable box and provide your number)
New York State DMV number
10 9
In county/state Under the name (if different from your name now) Last four digits of your Social Security number
I do not have a New York State DMV or Social Security number

Political Party Affidavit: I swear or affirm that

I wish to enroll in a political party • I am a citizen of the United States.
• I will have lived in the county, city or village for at least 30 days before
Democratic party the election.
Republican party • I will meet all requirements to register to vote in New York State.
11 Conservative party 12 • This is my signature or mark on the line below.
Working Families party • The above information is true, I understand that if it is not true, I can be
Other convicted and fined up to $5,000 and/or jailed for up to four years.

I do not wish to enroll in any political party and wish to be an independent voter
/ /
No party Signature or Mark in ink Date

(Optional) Register to donate your organs and tissues

Last Name By signing below, you certify that you are:
• 16 years of age or older
First Name Middle Initial Suffix
• Consent to donate all of your organs and tissues for
transplantation, research, or both;
Address • Authorizing the Board of Elections to provide your name and
identifying information to NYS Donate Life Registry for enrollment;
Apt Number City/Town/Village Zip Code • And authorizing the Registry to allow access to this information to federally regulated
organ procurement organizations and NYS-licensed tissue and eye banks and others
approved by the NYS Commissioner of Health hospitals upon your death.
Birth Date Gender
M F
Eye Color Height / /
Ft. In. Signature Date
Email DMV or ID NYC Number
 Qualifications for Registration Important!

You Can Use This Form To: If you believe that someone has interfered with your right to register or
• register to vote in New York State; to decline to register to vote, your right to privacy in deciding whether to
• change your name and/or address, if there is a change since you register or in applying to register to vote, or your right to choose your own
last voted; political party or other political preference, you may file a complaint with:
• enroll in a political party or change your enrollment;
• pre-register to vote if you are 16 or 17 years of age. NYS Board of Elections
40 North Pearl St, Suite 5
To Register You Must: Albany, NY 12207-2729
• be a U.S. citizen; Telephone: 1-800-469-6872;
• be 18 years old (you may pre-register at 16 or 17 but cannot vote until you TDD/TTY users contact the New York State Relay at 711;
are 18); or visit our web site - www.elections.ny.gov
• be a resident of the County, or of the City of New York at least 30 days
before an election; Your decision to register will remain confidential and will be used only for
• not be in prison for a felony conviction; voter registration purposes. Anyone not choosing to register to vote and/
• not claim the right to vote elsewhere; and or information regarding the office to which the application was submitted
• not found to be incompetent by a court. will remain confidential, to be used only for voter registration purposes.

Verifying your identity

We will try to check your identity before Election Day, through the DMV number (driver’s license number or non-driver ID
number), or the last four digits of your social security number, which you will fill in Box 9.

If you do not have a DMV or Social Security number, you may use a valid photo ID, a current utility bill, bank statement,
paycheck, government check or some other government document that shows your name and address. You may include
a copy of one of those types of ID with this form.

If we are unable to verify your identity before Election Day, you will be asked for ID when you vote for the first time.

To complete this form:

It is a crime to procure a false registration or to furnish false information to the Board of Elections.

Box 9: You must make one selection. For questions refer to Verifying your identity above.

Box 10: If you have never voted before, write “None”. If you can’t remember when you last voted, put a question mark (?).
If you voted before under a different name, put down that name. If not, write “Same”.

Box 11: Check one box only. Political party enrollment is optional but that, in order to vote in a primary election of a political
party, a voter must enroll in that political party, unless state party rules allow otherwise.

Rev. 05/04/2021