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.