LIHEAP Applicant Demographic Information

Required Household Information Section

The following fields should be required and apply to the entire household:

Household Information - County of Residence(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Country Phone Number

Are you, or anyone in your household, between the ages of 14 and 24, not disabled, unemployed, and not currently attending school?(Required)

If Yes, please provide name(s).

Benefits Received - Please include checkboxes for all that apply:(Required)

Applicant Information - Full Name(Required)

First Middle Last

Gender(Required)

Marital Status(Required)

Work Status(Required)

Health Insurance

Additional Household Member 1 - County of Residence

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Country Phone Number

Are you, or anyone in your household, between the ages of 14 and 24, not disabled, unemployed, and not currently attending school?

If Yes, please provide name(s).

Benefits Received - Please include checkboxes for all that apply:

Applicant Information - Full Name

First Middle Last

Gender

Marital Status

Work Status

Health Insurance

Additional Household Member 2 - County of Residence

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Country Phone Number

Are you, or anyone in your household, between the ages of 14 and 24, not disabled, unemployed, and not currently attending school?

If Yes, please provide name(s).

Benefits Received - Please include checkboxes for all that apply:

Applicant Information - Full Name

First Middle Last

Gender

Marital Status

Work Status

Health Insurance

Additional Household Member 3 - County of Residence

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Country Phone Number

Are you, or anyone in your household, between the ages of 14 and 24, not disabled, unemployed, and not currently attending school?

If Yes, please provide name(s).

Benefits Received - Please include checkboxes for all that apply:

Applicant Information - Full Name

First Middle Last

Gender

Marital Status

Work Status

Health Insurance

Additional Household Member 4 - County of Residence

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Country Phone Number

Are you, or anyone in your household, between the ages of 14 and 24, not disabled, unemployed, and not currently attending school?

If Yes, please provide name(s).

Benefits Received - Please include checkboxes for all that apply:

Applicant Information - Full Name

First Middle Last

Gender

Marital Status

Work Status

Health Insurance

Additional Household Member 5 - County of Residence

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Country Phone Number

Are you, or anyone in your household, between the ages of 14 and 24, not disabled, unemployed, and not currently attending school?

If Yes, please provide name(s).

Benefits Received - Please include checkboxes for all that apply:

Applicant Information - Full Name

First Middle Last

Gender

Marital Status

Work Status

Health Insurance

Additional Household Member 6 - County of Residence

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Country Phone Number

Are you, or anyone in your household, between the ages of 14 and 24, not disabled, unemployed, and not currently attending school?

If Yes, please provide name(s).

Benefits Received - Please include checkboxes for all that apply:

Applicant Information - Full Name

First Middle Last

Gender

Marital Status

Work Status

Health Insurance

Additional Household Member 7 - County of Residence

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Country Phone Number

Are you, or anyone in your household, between the ages of 14 and 24, not disabled, unemployed, and not currently attending school?

If Yes, please provide name(s).

Benefits Received - Please include checkboxes for all that apply:

Applicant Information - Full Name

First Middle Last

Gender

Marital Status

Work Status

Health Insurance

Additional Household Member 8 - County of Residence

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Country Phone Number

Are you, or anyone in your household, between the ages of 14 and 24, not disabled, unemployed, and not currently attending school?

If Yes, please provide name(s).

Benefits Received - Please include checkboxes for all that apply:

Applicant Information - Full Name

First Middle Last

Gender

Marital Status

Work Status

Health Insurance

Additional Household Member 9 - County of Residence

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Country Phone Number

Are you, or anyone in your household, between the ages of 14 and 24, not disabled, unemployed, and not currently attending school?

If Yes, please provide name(s).

Benefits Received - Please include checkboxes for all that apply:

Applicant Information - Full Name

First Middle Last

Gender

Marital Status

Work Status

Health Insurance

If your household has more than 10 members, a UETHDA representative will contact you to collect information for any additional household members.