Program Year 2024 – 2025 Energy Assistance Application Packet

Byrd Barr Place administers the Low Income Home Energy Assistance Program (LIHEAP), the State Home
Energy Assistance Program (SHEAP), and the Puget Sound Energy Home Energy Lifeline Program (PSE
HELP). Households can qualify for LIHEAP or SHEAP, and may also qualify for PSE HELP; see the eligibility
guidelines below. You can apply for LIHEAP, SHEAP, and PSE HELP by completing this packet.
Alternatively, you can apply for PSE HELP at pse.com.

Eligibility
Households must meet all three of the following requirements:
1. Your household must be within the Seattle city limits. ZIP codes 98177 and 98133 are served by
two different agencies; please call to see if you are within our service area. We do not serve ZIP
codes 98148 or 98168 in unincorporated Seattle.
2. Your household’s monthly income must be at or below 150% of the federal poverty line. See
income eligibility guidelines below and larger household sizes on our website at
byrdbarrplace.org/energy. Eligibility is based on the month prior to your application signature date.
We can assess for 1, 3, or 12 months of income. A 20% deduction is taken on all earned income
taxed at the time of payout.

Number of LIHEAP Average SHEAP Average PSE HELP Average

Household Monthly Income Monthly Income Monthly Income
Members Maximum Maximum Maximum
1 person $1,833 $5,887 $6,475
2 people $2,555 $6,729 $7,400
3 people $3,228 $7,570 $8,325
4 people $3,900 $8,408 $9,246
5 people $4,573 $9,083 $9,988

3. Your household must have an active energy utility account with Seattle City Light, oil, and/or
Puget Sound Energy, or your household pays energy costs as part of your rent.

How to Apply

Mail Drop Off Email Online

722 18th Ave 722 18th Ave energyassistance@ tfaforms.com/5052144

Seattle, WA 98122 Seattle, WA 98122 byrdbarr.place
Monday – Friday
9 a.m. – 5 p.m.

*Please note that your application expires 90 days from the signature date, and we are unable to
accept an incomplete application that is dropped off at our office.
Required Documents

1. Heating Type Document

• Copy of a Seattle City Light (SCL) electric bill and/or Puget Sound Energy (PSE) bill and/or oil bill.
– OR –
If you pay your heat cost as a flat rate included in your rent, you must instead provide all three of
these documents:
• Heat with Rent (HWR) verification form signed and dated by landlord.
• Copy of a signed rental lease stating that heat is included with rent.
• A rent receipt, rental ledger, or recertification letter from the last 6 months that shows recent
residency at current address.

2. Social Security Card/Documentation

Please provide social security cards/documentation for ALL household members living in the
home. This includes adults and minors living in the household.
• U.S. Social Security Card
For any household member missing their social security card, a U.S. birth certificate or U.S.
passport, plus one of the following alternatives that show their full social security number (SSN)
are required:
• W-2 Form with full SSN (including W-2C, W-2G, etc.)
• SSA-1099 Form with full SSN (including SSA-1099-SM, SSA-1099-R-OP1, etc.)
• Non-SSA 1099 Form with full SSN (including 1099-DIV, 1099-MISC, etc.)
• 1098 Form with full SSN (including 1098-C, etc.)

3. Income Documentation for the Three Months Prior to the Application Signature Date. All
household members that are 18 years and older must provide income documentation. See income
types below and the corresponding documentation required.
• Earned income: Must provide pay stubs from the previous month from when you sign the
application. For pay stubs, please refer to pay date (not pay period) to determine for which
month of income it is valid. If you cannot provide any pay stubs you must fill out the Self-
Declaration of Income Form.
• SSA, SSI, Pension, TANIF, and ABD: For any income documentation award, please provide the
income letter. If you can’t provide social security benefits, please provide a bank statement.
• Self-employed: Please fill out the Self-Employed Income Form regarding your small business.
We need itemized receipts dated in the three previous months, and they must be for allowable
deductions only according to the policy. Take a standard 50% deduction for each month of self-
employment, if earnings are more than the allowable standard deduction AND the household
member can provide proof of self-employed business, such as a business card, bank statement,
or a screenshot of website.
• Child support: Provide information of income in regard to child support, such as official court
statements. If it is paid in cash, please provide a bank statement and highlight it. Also fill out the
Self-Declaration of Income Form stating why you can’t provide the documents regarding child
support and put the amount that you received in the last three months.
• No income: Please fill out the Declaration of No Income Form if you do not have any source of
income. Only fill this out if you have received $0 earned income or benefits.
• Income, but no documentation: Please fill out the Self-Declaration of Income Form if you
cannot provide documents of pay stubs or social security income benefits.
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 Are You Interested in Other Programs We Offer?

Please check the boxes for the programs you are interested in. Note: Returning
this form does not guarantee assistance. Please visit our website at
byrdbarrplace.org/energy or call us at for eligibility requirements and program and
application updates.

LIHEAP FURNACE REPAIR PROGRAM (FRP)

Eligible LIHEAP households who are homeowners can apply to receive a
furnace cleaning, repair, or replacement, up to $10,000.

LIHEAP AIR CONDITIONER PROGRAM (AC)

Eligible LIHEAP households can apply for a portable air conditioner unit.

Want to stay up-to-date on your application? Opt-in to receive text messages

from Byrd Barr Place.

I would like to opt-in to receive text messages.

By checking this box, I agree to receive text messages from Byrd Barr Place in
relation to my application status and any additional information or documents
that may be needed. I acknowledge that I may receive text messages regarding
additional programs for which I may be eligible.

PHONE NUMBER:

Did you know you can also apply for the Seattle City Light Discount Program?

Eligible households can enroll in the City of Seattle’s Utility Discount Program (UDP),
which offers a 60% discount on Seattle City Light bills and a 50% discount on Seattle
Public Utilities bills. Apply directly with Seattle City Light for this program. Go to
seattle.gov/human- services/services-and-programs/utility-discount-program or call
206-684-0268 to speak to a city representative.
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 Energy and Money Savings Tips
Below are ways to help you save money and use less energy. To qualify for LIHEAP, please review these
tips and sign below verifying that you’ve read them.

• Unplug electronic devices when not in use or when leaving home.

• Consider investing in a power strip to easily turn off multiple devices.
• Turn off lights in rooms that aren’t being used.
• Reduce your refrigerator’s temperature (36 to 38 degrees).
• Make sure appliances are turned off after each use.
• Consider replacing bulbs with energy efficient lighting (CFL and LED lightbulbs).
• Seal drafts in windows and doors with weather stripping, caulking, or plastic film.
• Avoid using space heaters as much as possible, as they are expensive, unsafe, and not the most energy
efficient when it comes to heating your entire home.
• Vacuum vents and heating baseboards regularly.
• Add light colored curtains to windows and keep shades open during the day for sunlight and closed
at night to keep warm air in.
• Consider installing a water saving shower head.
• Lower water heaters thermostat to 120 degrees.
• Dust light fixtures regularly.
• Take showers, not baths.
• Run the dishwasher with full loads only and let dishes air dry.
• Lower the thermostat every time you leave the house.
• Wash full loads of laundry with cold water, air dry clothes, and clean lint trap.
• Raise the heat temperature in your home gradually, since sudden increases will substantially
increase your energy usage.
Rebates for energy efficient appliances, showerheads, and light bulbs are available. Go online or call your
energy advisor at Seattle City Light or Puget Sound Energy for more information and how to apply!
Seattle City Light: Call (206) 684-3800, email SCLEnergyAdvisor@seattle.gov or go to seattle.gov/light/conserve
Puget Sound Energy: Call 1-800-562-1482, email EnergyAdvisor@pse.com or go to pse.com/rebates

I acknowledge that I have read the above Energy and Money Saving Tips.

Applicant Signature: Date:

Email:

PY 2024-2025-EN-EST 6
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 Household Income Information Form (All Adults 18+)
(Do not include the current month)
Household Member Month: Month: Month:
#1 Name:

Notes: Earned Income Earned Income Earned Income

$ $ $
$ $ $
No Income No Income No Income
SSA: $ SSA: $ SSA: $
SSI: $ SSI: $ SSI: $
GA: $ GA: $ GA: $

TANF: $ TANF: $ TANF: $

Other: $ Other: $ Other: $

Household Member Month: Month: Month:

#2 Name:

Notes: Earned Income Earned Income Earned Income

$ $ $

$ $ $
No Income No Income No Income
SSA: $ SSA: $ SSA: $

SSI: $ SSI: $ SSI: $

GA: $ GA: $ GA: $

TANF: $ TANF: $ TANF: $

Other: $ Other: $ Other: $

Household Member Month: Month: Month:

#3 Name:

Notes: Earned Income Earned Income Earned Income

$ $ $

$ $ $

No Income No Income No Income

SSA: $ SSA: $ SSA: $
SSI: $ SSI: $ SSI: $

GA: $ GA: $ GA: $

TANF: $ TANF: $ TANF: $

Other: $ Other: $ Other: $

PY 2024-2025-EN-INC 8
 Heat With Rent (HWR) Verification Form
• This form MUST be completed and signed by a building manger or landlord.
• This form MUST be accompanied by a lease that is dated within the last year, and shows
heating costs is included with rent.
• This form MUST be accompanied by a document showing recent payments at your address dated
within the last six months, such as a recent rent receipt, rental ledger, or recertification letter.

I do hereby declare that is a tenant at:

Client’s Full Name

Apartment Name

Street Address Apt # ZIP Code

and has resided there since ,

Month Year

The dwelling’s primary heat source comes from: Electricity Gas

Is it stated in the rental agreement, that the payment for heat is included in the
monthly rent? Yes No

Manager/Landlord (print name):

Signature: Date:

Email: Telephone:

I certify that the above information is true and accurate to the best of my knowledge.

PY 2024-2025-EN-HWR 9
 Declaration Statement of No Income (DSNI)

I, , do hereby declare that I have not received any income for the
(full name)
month(s) or pay date(s) listed below.

This LIHEAP application is signed in the month of .

Which of the three months prior to the signature date did you not receive income?

July 2024 December 2024 May 2025

August 2024 January 2025 June 2025
September 2024 February 2025 July 2025
October 2024 March 2025 August 2025
November 2024 April 2025

(REQUIRED) The reason that I had no income for the month(s) listed above is:

(REQUIRED) I have been meeting my basic living needs for food, shelter, and utilities by:

I certify that the information contained above is complete and accurate to the best of my knowledge. I understand
that I am signing this statement under penalty of prosecution if I knowingly give false information, which results in
assistance received for which I am not eligible.

Signature: Date:

EAP Staff Signature: Date:

PY 2024-2025-EN-DSNI 10
 Self-Declaration of Income (SDI)

I, , do hereby state that the following dollar amounts represents my

income for the three months prior to the date of my application:

Months: Amount: Gross Net

1. 1.
2. 2.

3. 3.

Income Type:

Cash Personal Check Direct Deposit Benefit Earned Income

Other:

(REQUIRED) I received this income from:

(REQUIRED) I could not provide any income documents because:

Please submit any documentation showing the income received, such as a bank statement, receipt,
letter, personal check, etc.

Applicant Signature: Date:

EAP Staff Signature: Date:

PY 2024-2025-EN-SDI 11
 Self-Employed Declaration of Income (SEDI)
Business Name: Business Type:

I, , declare that I earned the gross income, before business expenses were
deducted for the following months:

1) 2) 3)

$ $ $

To deduct business expenses, please check one option:

I will provide itemized receipts dated in the three previous months. Please call 206-812-4940 to have a copy
of a list of allowable deductions mailed to you, or email energyassistance@byrdbarr.place for a copy.
I do not have receipts. Please apply a standard deduction. (Recommended)

Please submit the following required documentation with this form.

1. Proof of business, such as a business license, business card, etc.
2. Business ledger, bank deposit statements, invoices, or screenshots of app-based earnings.

I certify that the information contained in this employment statement is complete and accurate. I understand that I am signing
this declaration under penalty of criminal prosecution if I knowingly give false information that results in assistance for which I
am not eligible.

Client Signature: Date:

EAP Staff Signature: Date:

*This section below is to be completed by EAP Staff. Do NOT complete.

Gross Income Standard Deduction Total Allowable Deduction Total Net

Month 1 $ $ $ $

Month 2 $ $ $ $

Month 3 $ $ $ $

TOTAL $ $ $ $

AVERAGE MONTHLY NET INCOME: $

PY 2024-2025-EN-SEDI
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 Air Conditioner Request Form
Eligible LIHEAP households can now apply for air conditioning units. Eligible households must be approved for the current
LIHEAP program year before applying. This document outlines requirements, terms, and conditions for receiving and operating
the air conditioning unit. Please read it carefully. This document should be retained for the client’s records if they choose to
receive an air conditioning unit.
Air Conditioning Unit Specifications and Operating Requirements
• The unit is a free-standing portable unit, weighing approximately 55 to 70 pounds with dimensions approximately 18
inches by 15 inches wide and up to 36 inches tall. It does not sit in a window.
• The unit must be plugged into a wall socket and set up on a level surface near a window.
• The main part of the unit comes fully assembled but includes a hose and window connectors that must be attached or
assembled before the unit can be operated.
• Upon delivery and during periods of non-use, the unit should be stored upright. Portable AC units must sit upright for at
least 24 hours prior to use.
• The unit requires light periodic maintenance, including cleaning air filters and draining any moisture accumulation. The
unit will include a use manual with additional information and instructions.
• The unit is for the recipient’s households use only.
Additional Important Terms
• We are using a third-party to distribute the unit to you, and we will have them deliver it to the shipping address you
designate below, or to an address previously agreed upon with your property management.
• Upon delivery, the recipient takes all responsibility for the unit, including but not limited to movement, assembly,
installation, and proper use.
• We make no warranties for and accept no responsibility in connection with the use of the unit. In addition, we are not
responsible or liable for any defect, damage, accidents, or injuries resulting from handling or operating the unit, whether as
directed by the user manual or otherwise.
• Please refer all comments, concerns, replacements, or other requests about the unit to the unit manufacturer, including any
defects, damages, or malfunction issues. We cannot assist with any of these matters.
• We are providing the unit to you as a one-time benefit. A household can only receive one unit one time. We will not
provide additional or replacement units.

Next Steps
• You will receive an email letting you know once your application has been approved, and it will include next steps on how you
will be receiving your unit.

By signing this form you are indicating that you wish to receive an AC unit.
If you are 1) not in need, 2) unwilling or unable to receive an AC unit, or 3) if you have already received an AC unit through this
program, please check here:
I have applied for LIHEAP since Oct. 1, 2024.
Client’s Printed Name: EAP Staff Signature:
Client’s Signature: Case Manager Signature:
Date:

Email Address:
Please indicate who this email address belongs to: Self Case Manager Other
Client Phone:
Shipping Address:
Residential Address:

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