Home Energy Assistance

Title VI of the Civil Rights Act prohibits discrimination by anyone who receives federal funds directly or indirectly towards a beneficiary of any federally funded program. The Subgrantee must make each applicant aware of the rights and responsibilities associated with applying for and receiving LIHEAP benefits. Rights and responsibilities as reflected on the application are as follows; however, Subgrantee workers must be mindful to treat all clients with dignity, courtesy and respect 1. I understand that my application will be shared with the providers of the selected additional services 2. I understand the information on this application will be kept confidential and only be shared as indicated. No information will be sold, loaned, rented or otherwise disclosed except as indicated on this application 3. I understand that I have the right to appeal any decision regarding this application which I consider improper, any delay in decision or delivery of services, and any disagreement with benefit amount. 4. I understand that I must help establish my eligibility by providing as much information as I can about my circumstances. 5. I authorize the LIHEAP affiliate to share information relating to my application with my utility service provider(s) to determine my eligibility or benefit amount. 6. I give permission to the Arkansas Energy Office (AEO) to use information provided on my application for purposes of reporting, research, evaluation, and analysis of the program. 7. I authorize my utility supplier(s) to release my account information to Arkansas Energy Office (AEO) or its de‐ signee(s). 8. I understand that my utility service provider will have no control over the data disclosed pursuant to this consent and will not be responsible for monitoring or taking any steps to ensure that the LIHEAP office maintains the confidentiality of the data or uses the data as I have authorized. 9. I understand that no person may be denied assistance on the basis of race, color, sex, age, handicap, religion, national origin, or political belief. 10. I understand that my signature on this application authorizes the agency to verify information about me or any household member and/or use it as a release to secure information needed to determine my eligibility for services. 11. I understand that if I receive assistance to which I am not entitled as a result of withholding information or knowingly providing false or fraudulent information regarding me and/or household members, I must repay the cost of any assistance and may face penalty of criminal prosecution. 12. The information given on this application is true to the best of my knowledge and belief. I understand that this form is signed subject to penalties for perjury. Additionally, the Subgrantee must recognize that a client has the right to request information and expect a response. The Subgrantee must not ignore inquiries related to eligible services and eligibility, payments, and rights and responsibilities.