LIHEAP Request for Serivce

To complete the LIHEAP Request for Service, you will need to complete all 5 sections on this page.

Section A: Signature Form - You will need to click the Download Form to print this form to sign and hold onto this form until you are given direction from a C.E.F.S. staff member.

Section B: Head of Household Information - This information is for the person who is the Head of the Household completing this LIHEAP Request for Service.

Section C: Other Household Members - There is space provided for information on ALL the members of the household.

Section D: Utility Information - Section D is only completed IF you are responsible for paying any of your utilities.

Section E: Utility Information - Section E is only completed IF your utilities are part of your rent payment.

PLEASE NOTE: CLOSING THIS BROWSER BEFORE SUBMITTING, DELETES ALL INFORMATION.

Section A: Signature Form

Click the Download Form button to download the signature page. This form is needed to officially complete your LIHEAP Request for Service. Hold on to the Signature Form until you are given direction from a C.E.F.S. staff member.

LIHEAP Request for Service
Section B: Head of Household Information
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Does the Head of Household have a disability?
Is Head of Household a veteran?
Is Head of Household a farmer?
Ethnicity?
Education Level
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Income Sources
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Housing Status
Subsidized Housing
Family Type
SNAP (Food Stamps)

Section C: Complete an Other Household Member section for each member of the household.

{If you have more than 5 additional household members, the following questions will be asked when you are contacted by a C.E.F.S. staff member.}

Other Household Member #1

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Household Member #1 - Ethnicity?
Disabled? (HM#1)
Veteran? (HM#1)
Household Member #1 - Education Level

Other Household Member #2

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Household Member #2 - Ethnicity?
Disabled? (HM#2)
Veteran? (HM#2)
Household Member #2 - Education Level

Other Household Member #3

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Household Member #3 - Ethnicity?
Disabled? (HM#3)
Veteran? (HM#3)
Household Member #3 - Education Level

Other Household Member #4

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Household Member #4 - Ethnicity?
Disabled? (HM#4)
Veteran? (HM#4)
Household Member #4 - Education Level

Other Household Member #5

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Household Member #5 - Ethnicity?
Disabled? (HM#5)
Veteran? (HM#5)
Household Member #5 - Education Level

Utility Information

Section D: This section is completed IF you are responsible for paying any of your utilities.

(If your utilities are part of your rent payment, keep scrolling to Section E.)

What do you use to heat your home?
Are you responsible for paying this bill?
Is your service on?
Are you applying for new services wih this company?
Do you have an old bill?
Do you have a disconnect notice?
Is your service on? (electric)
Are you responsible for paying the electric bill?
Are you applying for new services wih this company? (electric)
Do you have an old bill? (electric)
Do you have a disconnect notice? (electric)
Do you use any supplemental form of heating?
Supplemental Heating
My home has:

* If your home has AC window/wall units, please answer the following:

Where ae the units located?

Section E: This section needs completed IF your utilities are part of your rent payment.

I do not pay any utility company directly, my heat an electric are inclued i my rent:
Do you use any supplemental form of heating?
Supplemental Heating
My home has:

* If your home has AC window/wall units, please answer the following:

Where are the units located?
Do you pay for water and sewer sevices?

When you click Submit:

  • Your Request for Service will be emailed to a staff member of C.E.F.S. LIHEAP.

  • After receiving your Request for Services, you will be contacted within 2 business days by a C.E.F.S. representative.

  • You will be given a list of required documentation needed for your Request for Service.

  • You will be instructed how to submit the required documents to C.E.F.S.

  • Your Request for Service will be effective on the date all required documentation is received.

Reminder: A complete LIHEAP Request for Service requires:

  • Completed Signature Form (Section A - top of the page). You will need to hold on to this form and you will be given directions when you are contacted by a C.E.F.S. staff member.

  • Submission of required documents.

Thank you for submitting your LIHEAP Request for Service!

Be sure to download and complete the Signature Form (Section A). You will need to hold on to the Signature Form until you are contacted by a C.E.F.S. staff member and given directions about submitting the form.

Click the Your Rights button below to find information on appeals.