Agency Use Only

Application ID: 2635013193

Application for Financial Help to Heat or Cool Your Home SSN: 551872375
Low Income Home Energy Assistance Program (LIHEAP)
How to apply for LIHEAP
1. Fill out the attached application. Answer every question. If your application is not complete, it will be delayed or
returned.
2. Send your completed application and documents to the LIHEAP agency in the county you live in. You can find your LIHEAP
agency on the back of this page.
When to apply for LIHEAP - Energy Assistance (EA)
• Send your application on or after October 1, 2024 if: Any member of your household is age 60 or over, or if any
household member is disabled.
• Send your application on or after November 1, 2024 if: Your household doesn’t include a person age 60 or over, or who
is disabled.
• The last day to apply for EA is May 31, 2025.
When to apply for LIHEAP - Energy Crisis Intervention Program (ECIP)
• You can apply for Winter ECIP from November 1, 2024 to May 31, 2025 for elderly/disabled households, and December 1,
2024 to May 31, 2025 for all other households.
• All households can apply for Summer ECIP from June 1, 2025 to September 30, 2025.
• ECIP requires the household to provide a disconnect notice for energy payments.
How to apply for ECIP (Crisis)
• If you have not received EA for this year, you must complete the entire application.
• If you received EA from October 1, 2024 to May 31, 2025, and there are no changes you do not need to complete a new
application, contact your local agency.
After you send your application
The LIHEAP agency will review your application:
• You will receive notification of approval, denial, or requests for additional information from the Family Support Division.
Important:
• Continue to make utility payments to your utility company.
• Benefits are dependent on available funding.
• 1 bill + 1 meter = 1 Household

PROGRAM DESCRIPTION
ENERGY ASSISTANCE (EA) HOUSEHOLD MONTHLY INCOME AMOUNTS

Below is the maximum payment amount your household can receive. SIZE 0%-60% STATE MEDIAN INCOME (SMI)

Natural Gas $326 1 2,751

Tank Propane $495 2 3,598
Electric $318
3 4,445
Fuel Oil $326
4 5,291
Wood $219
Kerosene $153 5 6,138
Cylinder Propane $177 6 6,984
ENERGY CRISIS INTERVENTION PROGRAM (ECIP) 7 7,143
8 7,302
Up to $800 November 1 through May 31
Winter
with a disconnect notice for energy payments 9 7,461
10 7,619
Up to $300 June 1 through September 30
Summer For households with more than 10 members, add $159 to the
with a disconnect notice for energy payments
maximum monthly income for each additional household member.

Submitted Date Time: 03/22/2025 4:46:11 AM Page 1 of 6 LIHEAP (9/2024)

 Where to send your LIHEAP Application
Search for your local office by referring to the county in which you live.
Audrain, Boone, Callaway, Cole, Cooper, Howard, Moniteau, Jefferson, Franklin
Osage Jefferson-Franklin Community Action Corporation (JFCAC)
Central Missouri Community Action (CMCA) PO Box 920
800 N Providence Rd Ste 200 Hillsboro, MO 63050-0920
Columbia, MO 65203-4300 Phone number: (636) 789-2686 Fax (636) 789-2866
Phone number: (573) 443-1100 Fax (573) 370-1212
Camden, Crawford, Gasconade, Laclede, Maries, Miller,
Website: https://cmca.us/get-help/energy-assistance/
Phelps, Pulaski
St. Louis County Missouri Ozarks Community Action, Inc. (MOCA)
Community Action Agency of St. Louis County (CAASTLC) PO Box 69
2709 Woodson Rd Richland, MO 65556-0069
Overland, MO 63114-4817 Phone number: (573) 765-3263 Fax (573) 232-1638
Phone number: (314) 446-4420 Fax (314) 446-4480
Carroll, Chariton, Johnson, Lafayette, Pettis, Ray, Saline
Andrew, Buchanan, Clinton, DeKalb Missouri Valley Community Action Agency (MVCAA)
Community Action Partnership of Greater St. Joseph (CAPSTJOE) 1415 S Odell Ave
1322 N. 36th St. Marshall, MO 65340-3144
St. Joseph, MO 64506 Phone number: (660) 542-0418 Fax (660) 831-5039
Phone number: (816) 233-8281 Fax (816) 233-8262
Lewis, Lincoln, Macon, Marion, Monroe, Montgomery, Pike,
IVR: (816) 693-6868
Ralls, Randolph, Shelby, St. Charles, Warren
Atchison, Gentry, Holt, Nodaway, Worth Northeast Community Action Corporation (NECAC)
Community Services, Inc. of Northwest Missouri (CSI) 815 Business Highway 61 N
PO Box 328 Bowling Green, MO 63334-1351
Maryville, MO 64468-0328 Phone number: (573) 324-0120 Fax (573) 213-4858
Phone number: (660) 582-3113 Fax (660) 582-2965
Adair, Clark, Knox, Schuyler, Scotland
Barton, Jasper, Newton, McDonald Community Action Partnership Northeast Missouri (CAPNEMO)
Economic Security Corporation of Southwest Area (ESC) PO Box 966
PO Box 207 Kirksville, MO 63501-0966
Joplin, MO 64802-0207 Phone number: (660) 665-9855 Fax (660) 665-6557
Phone number: (417) 781-0352 Fax (417) 781-2011 Email: LIHEAP@campnemo.org
Bollinger, Cape Girardeau, Iron, Madison, Perry, St. Francois, Douglas, Howell, Oregon, Ozark, Texas, Wright
Ste. Genevieve, Washington Ozark Action, Inc. (OAI)
East Missouri Action Agency (EMAA) 710 E Main St
PO Box 308 West Plains, MO 65775-3307
Park Hills, MO 63601-0308 Phone number: (417) 256-6147 Fax (417) 256-0333
Phone number: (573) 431-0103 Fax (573) 431-7377
Barry, Christian, Dade, Dallas, Greene, Lawrence, Polk, Stone,
Dunklin, Mississippi, New Madrid, Pemiscot, Scott, Stoddard Taney, Webster
Delta Area Economic Opportunity Corporation (DAEOC) Ozarks Area Community Action Corporation (OACAC)
99 Skyview Rd 215 S Barnes Ave
Portageville, MO 63873-9180 Springfield, MO 65802-2204
Phone number: (573) 379-3851 Fax (573) 379-9139 Phone number: (417) 864-3460 Fax (417) 864-3472
Caldwell, Daviess, Grundy, Harrison, Linn, Livingston, Mercer, Butler, Carter, Dent, Reynolds, Ripley, Shannon, Wayne
Putnam, Sullivan South Central Missouri Community Action Agency (SCMCAA)
Green Hills Community Action Agency (GHCAA) PO Box 6
1506 Oklahoma Ave Winona, MO 65588-0006
Trenton, MO 64683-2587 Phone number: (800) 325-4633 Fax (573) 325-4543
Phone number: (660) 359-3907 Fax (660) 359-2038
Jackson, Clay, Platte
City of St. Louis, Wellston Mid America Assistance Coalition (MAAC)
Urban League (ULSTL) 4001 Dr. Martin Luther King JR. DR., Suite 270
1408 N. Kingshighway Blvd. Kansas City, MO 64130-2350
St. Louis, MO 63113 Phone number: (816) 768-8900 Fax (816) 768-8901
Phone number: (314) 615-3632 Fax (314) 615-3632
Bates, Benton, Cass, Cedar, Henry, Hickory, Morgan, St. Clair,
Vernon
West Central Missouri Community Action Agency (WCMCAA)
112 W 4th Street
Appleton City, MO 64724-1402
Phone number: (660) 476-2185 Fax (660) 476-5901

Submitted Date Time: 03/22/2025 4:46:11 AM Page 2 of 6 LIHEAP (9/2024)

 Agency Use Only
Date Stamp
Application for Financial Assistance for Home Energy Costs
Low Income Home Energy Assistance Program (LIHEAP)
Part 1 – Enter Contact Information
Name
Shonna R Davis
Home Address (Or address you are moving to) Apt# City State Zip Code
942 Clark Street N/a Jackson Missouri 63755
Mailing Address (If different from home address) Apt# City State Zip Code

County of Residence Email Phone Number Cell Number

Cape Girardeau tishann31@gmail.com (573) 270-3635 (563) 270-3634

Part 2 – Complete All Household Members Information

List every person living in your household, starting with yourself. Fill in each box for every household member. If there are more
than 10 people living in your home, list the others on a separate sheet of paper.
Social U.S.
SNAP? Sex Birth Disabled? Relationship
Name Security Race Citizen?
Yes/No M/F Date Yes/No to You
Number Yes/No
Shonna Davis Yes 551-87-2375 F 08/26/1985 No SELF WHITE Yes

Tish James Yes 491-86-2884 F 01/29/1980 No Partner WHITE Yes

Emily Cotner Yes 589-27-0431 05/31/2008 No Daughter WHITE Yes

Do you own your home or are you buying your home?............................................................................................ Yes No
Has your home been weatherized by the local agency weatherization program?.................................................... Yes No
Is your home all electric?........................................................................................................................................... Yes No
Do you or a household member suffer from a life-threatening medical condition?................................................. Yes No

Part 3 - Enter Utility Information

• Indicate in the “Fuel Source For My Home” section below, DSS will only pay EA benefits for the fuel type selected under this
section.
Fuel Source For My Home
Natural Gas Tank Propane Electric Wood Cylinder Propane Fuel Oil Kerosene
List your supplier’s name
City of jackson
City Whose name appears on the account?
Jackson Shonna davis
Account Number
500118003
Are you currently without this energy source because it got disconnected or you’re out of fuel? Yes No
Are you currently in threat of not having this energy source selected above because it may be disconnected soon or you're
low on fuel? Yes No
If you answered yes to either question, please fill in the disconnection date or how much wood, propane, or prepaid

Submitted Date Time: 03/22/2025 4:46:11 AM Page 3 of 6 LIHEAP (9/2024)

electric you have: 3/25/2025
If you have a disconnect notice, send it with this application.
Additional Fuel Source For My Home Leave empty if your home is all electric. If all electric, make sure electric information is listed in the “Fuel Source For My Home” section.
1. Natural Gas Tank Propane Electric Wood Cylinder Propane Fuel Oil Kerosene
List your supplier’s name
Liberty utilities
City Whose name appears on the account?
Jackson Tish james
Account Number
200009896701
• If you or someone in your household suffers from a life threatening medical condition, send a medical statement from a
qualified doctor or nurse. The statement should indicate the household member has a life-threatening medical condition,
but does not have to state a diagnosis or condition.

Part 4 - Enter Information if You Don’t Pay the Utility Company Directly
The account is in my Landlord’s name and I pay my Landlord for my heating or cooling costs. Yes No
I live in subsidized housing or receive Section 8. Yes No
Heating costs are included in my rent. Yes No
Cooling costs are included in my rent. Yes No
Landlord's Name Phone Number
Area properties (573) 803-3111
Landlord’s Address
Kingshighway

Part 5 - Enter Household Income

If anyone in your household has income from a job or self-employment:
• Fill in this section to show all income anyone gets from tips, payments for service, and wages for all jobs, even if someone
has more than one job. If you need to list additional income, provide it on a separate sheet of paper.
• Send copies of documents that shows all gross income received by anyone last month, such as paystubs. Gross income is
income received before taxes are withheld. If anyone was employed in the last six (6) months but did not receive income
from that job last month, provide proof of final wages earned and last date worked from that employer.
List everyone in your home age 18 or older who received income from a job last month. (Include all jobs.)

Name Employer How Often Paid? Gross Pay Still Employed?

None 0 $0.00 No
Did anyone in the household get income from self-employment last month? Yes No
If yes, send a copy of the most recent Federal Income Tax Form 1040, including Schedule 1,
for each self-employed person along with your application.
Part 6 - Enter Court Ordered Child Support (if applicable)
Court-ordered Child Support that is paid to someone outside your household can be deducted so that it doesn’t count as
income. To receive this deduction, fill in your 8-digit Child Support case number below.
Did anyone pay court-ordered Child Support last month to someone outside of your household? Yes No

If yes, how much? Name of person who pays the Child Support

List the 8-digit Child Support Case Number

Submitted Date Time: 03/22/2025 4:46:11 AM Page 4 of 6 LIHEAP (9/2024)

Part 7 - Enter Other Income
• Send copies of documents showing income anyone received last month. If you need to list additional income for any
household members, send a separate sheet of paper with the information.
AMOUNT HOW OFTEN
SOURCES OF INCOME WHO RECEIVES THIS INCOME?
RECEIVED RECEIVED?
Social Security
Supplemental Security Income (SSI)
Temporary Assistance for Needy
Families (TANF)
Supplemental Aid to the Blind (SAB)
Blind Pension (BP)
Supplemental State Payments (SSP)
Foster Care
Alimony
Child Support
List 8-Digit Case Number:
Unemployment Compensation Tish james $320.00 Weekly
Veterans Benefits
Pensions
Railroad Retirement
Rent Received from Land or Buildings
Money Received from Friends, Family,
or Organizations
Armed Forces Allotment
Union Funds or Strike Benefits
Worker’s Compensation or Temporary
Private Disability
Other Unearned Income
Specify:
Part 8 - Enter Resource Information - Split this for household members.
If anyone in your household has savings or other accounts, fill in the total amounts of money everyone has in each type of
account.
Type Who's Account? How Much?
Checking: Single and/or Joint Accounts
Stocks/Bonds and Mutual Funds
IRA/KEOGH and/or Deferred Compensation Plans
Savings: Single and/or Joint Accounts
CDs, Annuities, and/or Money Markets
Part 9 - Notice That You Can Get A Fair Hearing - For Informational Purposes Only
As an applicant for the Low Income Home Energy Assistance Program (LIHEAP), you may request a hearing for the
following reasons:
1) If your LIHEAP application is denied.
2) If your LIHEAP application is not reviewed timely.
A request for a hearing can be made in writing, by phone, by fax, or in-person.

Submitted Date Time: 03/22/2025 4:46:11 AM Page 5 of 6 LIHEAP (9/2024)

Documents you must send with your application to avoid processing delays (send copies, originals will not be returned):
Application that is completely filled in, signed, and dated.
Proof of Social Security Number for everyone in the household. (Such as social security card, award letter, W-2)
Copies of utility and/or heating and cooling for your fuel sources, including any disconnection notices. The person listed on the
fuel bill must be a member of the household who is age 18 or older.

Papers you need to send if any member of your household got any income last month:
Proof of all income (both earned and unearned) from last month for all household members who got it. Household members who
are active SNAP recipients do not need to provide proof of these incomes.
Copies of the most recent Federal Income Tax Form 1040, including Schedule 1, for any household members who earned money
from self-employment last month.

Part 10 - Your Consent For The LIHEAP Agency To Process (Review) This Application
Read the Consent for Processing in the box below and sign. If you do not sign and date the application, your LIHEAP
application will not be processed.
I hereby apply for assistance under the LIHEAP laws of the State of Missouri administered by the Department of Social Services
(DSS). I declare that the information I have given is true, correct, and complete to the best of my knowledge. I realize that the
information which I have given on this application will need to be verified by the LIHEAP agency.

If any household member declared on my application is currently receiving SNAP, TANF, or Child Support, I hereby authorize the
LIHEAP agency to use my Family Support Division (FSD) file to see if we qualify for LIHEAP. I hereby authorize the LIHEAP agency,
FSD, and my fuel supplier to provide to one another any of my customer, application and account information (such as: service
address, energy source, customer account number, past due amount, notice of disconnection, etc.) to determine my eligibility
and to otherwise administer the program. to determine my eligibility and to otherwise administer the program. I give
permission to DSS to use information provided on this form for purposes of research, evaluation, and analysis of the program.

I understand that I may be fined, imprisoned, or both under state or federal law if I make false statements on this application in
order to get benefits I am not entitled to receive.

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature.
*Signature *Date
Shonna davis 03/22/25

Submitted Date Time: 03/22/2025 4:46:11 AM Page 6 of 6 LIHEAP (9/2024)