Backup Documents 08/08/2023 Item #16D 3 � 6 3
ORIGINAL DOCUMENTS CHECKLIST & ROUTING SLIP
TO ACCOMPANY ALL ORIGINAL DOCUMENTS SENT TO
THE BOARD OF COUNTY COMMISSIONERS OFFICE FOR SIGNATURE
Print on pink paper. Attach to original document. The completed routing slip and original documents are to be forwarded to the County Attorney Office
at the time the item is placed on the agenda. All completed routing slips and original documents must be received in the County Attorney Office no later
than Monday preceding the Board meeting.
**NEW** ROUTING SLIP
Complete routing lines#1 through#2 as appropriate for additional signatures,dates,and/or information needed. If the document is already complete with the
exception of the Chairman's signature,draw a line through routing lines#1 through#2,complete the checklist,and forward to the County Attorney Office.
Route to Addressee(s) (List in routing order) Office Initials Date
1. Wendy Klopf Community and Human GIrk 08/08/2023
Services
2. Minutes & Records Clerk of Court's Office M
3.
4.
PRIMARY CONTACT INFORMATION
Normally the primary contact is the person who created/prepared the Executive Summary. Primary contact information is needed in the event one of the addressees
above,may need to contact staff for additional or missing information.
Name of Primary Staff Wendy Klopf/CHS Phone Number 252-2901
Contact/ Department
Agenda Date Item was 08/08/2023 Agenda Item Number 16D3
Approved by the BCC
Type of Document AAA/ENHCE 203.02 Amendment Number of Original 1
Attached Documents Attached
PO number or account NA
number if document is
to be recorded
INSTRUCTIONS & CHECKLIST
Initial the Yes column or mark"N/A" in the Not Applicable column,whichever is Yes N/A(Not
appropriate. (Initial) Applicable)
1. Does the document require the chairman's original signature? NA
2. Does the document need to be sent to another agency for additional signatures? If yes, NA
provide the Contact Information(Name;Agency;Address;Phone)on an attached sheet.
3. Original document has been signed/initialed for legal sufficiency. (All documents to be WK
signed by the Chairman,with the exception of most letters,must be reviewed and signed
by the Office of the County Attorney.
4. All handwritten strike-through and revisions have been initialed by the County Attorney's NA
Office and all other parties except the BCC Chairman and the Clerk to the Board
5. The Chairman's signature line date has been entered as the date of BCC approval of the NA
document or the fmal negotiated contract date whichever is applicable.
6. "Sign here"tabs are placed on the appropriate pages indicating where the Chairman's NA
signature and initials are required.
7. In most cases(some contracts are an exception),the original document and this routing slip NA
should be provided to the County Attorney Office at the time the item is input into SIRE.
Some documents are time sensitive and require forwarding to Tallahassee within a certain
time frame or the BCC's actions are nullified. Be aware of your deadlines!
8. The document was approved by the BCC on 08/08/2023 and all changes made during WK N/A is not
the meeting have been incorporated in the attached document. The County an option for
Attorney's Office has reviewed the changes,if applicable. this line.
9. Initials of attorney verifying that the attached document is the version approved by the WK N/A is not
BCC,all changes directed by the BCC have been made,and the document is ready for the an option for
Chairman's signature. this line.
I:Forms/County Forms/BCC Forms/Original Documents Routing Slip WWS Original 9.03.04,Revised 1.26.05,Revised 2.24.05;Revised 11/30/12
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April 2021 -June 2024 EHEAP 203.21.04
AREA AGENCY ON AGING FOR SOUTHWEST FLORIDA,INC.
EMERGENCY HOME ENERGY ASSISTANCE PROGRAM
WHEREAS, the purpose of this Amendment is to replace Attachments XIII,XIV,XV,and XVII.
NOW THEREFORE,in consideration of the mutual covenants and obligations set forth herein,the receipt and sufficiency
of which are hereby acknowledged,the Parties agree to the following:
All provisions in the contract and any attachments thereto in conflict with this Amendment shall be and are hereby changed to
conform to this Amendment.
All provisions not in conflict with this Amendment are still in effect and are to be performed at the level specified in the contract.
This Amendment and all its attachments are hereby made part of the contract.
IN WITNESS THEREOF, the Parties hereto have caused this amendment, to be executed by their officials as
duly authorized; and agree to abide by the terms, conditions and provisions of this amendment as amended. This
Amendment is effective on the last date the Amendment has been signed by both Parties.
IN WITNESS WHEREOF,the Parties hereto have caused this contract to be executed by their undersigned officials as duly
authorized.
c /I I I II,`Digita�l�si nod by AREA
signed by
CONTRACT W Ya `1�laricela Morado
BOARD OF NTY COMMIA L(��N� 07.11 SOUTHWESA\F/LORID INC.Date: 2023.07.12
Tanya 09:56:49 -04'00' Y: '`�'o ratio 08:17:05 -04'00'
SIGNED BY: SIGNED B
NAME: Tanya R. Williams NAME: Maricela Morado
TITLE: Public Services Dept. Head TITLE: President and CEO
DATE: 07/11/2023 DATE: 07.12.23
As designee of the County Manager,
pursuant to Resolution No. 2018-202.
Ap,a .ved as to Form d Legality:
i
."..,16
Derek D. Perry
Assistant County Attorney
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ATTACHMENT XIII
INVOICE REPORT SCHEDULE
Report Number Posed Unop Date Due
1 April Advance Request* Upon Execution of Contract
2 May Advance Request* Upon Execution of Contract
3 April Expenditure Report May 9,2021
4 May Expenditure Report June 9,2021
5 June Expenditure Report July 9,2021
6 July Expenditure Report August 9,2021
7 August Expenditure Report September 9,2021
8 September Expenditure Report October 9,2021
9 October Expenditure Report November 9,2021
10 November Expenditure Report December 9,2021
11 December Expenditure Report January 9,2022
12 January Expenditure Report February 9,2022
13 February Expenditure Report March 9,2022
14 March Expenditure Report April 9,2022
15 April Expenditure Report May 9,2022
16 May Expenditure Report June 9,2022
17 June Expenditure Report July 9,2022
18 July Expenditure Report August 9,2022
19 August Expenditure Report September 9,2022
20 September Expenditure Report October 9,2022
21 October Expenditure Report November 9,2022
22 November Expenditure Report December 9,2022
23 December Expenditure Report January 9,2023
24 January Expenditure Report February 9,2023
25 February Expenditure Report March 9,2023
26 March Expenditure Report April 9,2023
27 April Expenditure Report May 9,2023
28 May Expenditure Report June 9,2023
29 June Expenditure Report July 9,2023
30 July Expenditure Report August 9,2023
31 August Expenditure Report September 9,2023
32 September Expenditure Report October 9,2023
33 October Expenditure Report November 9,2023
34 November Expenditure Report December 9,2023
35 December Expenditure Report January 9,2024
36 January Expenditure Report February 9,2024
37 February Expenditure Report March 9,2024
38 March Expenditure Report April 9,2024
39 April Expenditure Report May 9,2024
40 May Expenditure Report June 9, 2024
41 June Expenditure Report July 9, 2024
42 Final Close Out Report July 15,2024
*Advance based on projected cash need.
Note 1
Advance basis invoices,cannot be submitted to the Department of Financial Services(DFS)prior to April 1 or until the contract with the
Department has been executed and uploaded to DFS Florida Accountability Contract Tracking System(FACTS).Actual submission of
all vouchers to DFS is dependent on the accuracy of the Receipts and Expenditure Report.
Note 2
Report numbers 5 through 14 shall reflect an adjustment of one-tenth of the total advance amount,on each of the reports,repaying advances
issued for the first one or two months of the agreement.The adjustment shall be recorded in Part C, 1 of the report(Attachment XII).Note
3
Submission of invoices may or may not generate a payment request.If final invoice reflects funds due back to the Department,payment
is to accompany the final close-out invoice. co
A
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ATTACHMENT XIV
POVERTY INCOME GUIDELINES
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM(LIHEAP)
POVERTY INCOME GUIDELINES*
EFFECTIVE JULY 1,2023
PEOPLE IN THE HOUSEHOLD 60% SMI
1 $27,735
2 $36,269
3 $44,803
4 $53,337
5 $61,870
6 $70,404
7 $72,004
8 $73,605
Please refer to the Federal Poverty Guidelines (FPG)Benefits Matrix for income ranges for
households with 9-or-more individuals.
*These figures are based on the 2022 U.S. Department of Health and Human Services (HHS) poverty
guidelines published in the Federal Register on January 19,2023.
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ATTACHMENT XV
LIHEAP PAYMENT MATRIX
ATTACHMENT'A'
LOW-INCOME HOME ENERGY ASSISTANCE PROGRAM PAYMENT MATRIX-Updated FY 2023/2024
HOME ENERGY BENEFITS1 AND POVERTY LEVELS Max Income
BY HOUSEHOLD INCOME AND SIZE Value Columnt
Number of People 50%or Less >50%-70% >70%-85% >85%-100%
in Household of Max Income Value of Max Income Value of Max Income Value of Max Income Value
1 $ 13,868 $ 13,869 $ 19,415 $ 19,416 $ 23,575 $ 23,576 $ 27,735 d
2 $ 18,135 $ 18,136 $ 25,388 $ 25,389 $ 30,829 $ 30,830 $ 36,269 0
3 $ 22,402 $ 22,403 $ 31,362 $ 31,363 $ 38,083 $ 38,084 $ 44,803 3
a
4 $ 26,669 $ 26,670 $ 37,336 $ 37,337 $ 45,336 $ 45,337 $ 53,337 L
5 $ 30,935 $ 30,936 $ 43,309 $ 43,310 $ 52,590 $ 52,591 $ 61,870
6 $ 35,202 $ 35,203 $ 49,283 $ 49,284 $ 59,843 $ 59,844 $ 70,404 m
7 $ 36,002 $ 36,003 $ 50,403 $ 50,404 $ 61,203 $ 61,204 $ 72,004 ,
8 $ 36,803 $ 36,804 $ 51,524 $ 51,525 $ 62,564 $ 62,565 $ 73,605
Number of People At least 75%but no more than Over 100% but no more than Over 125%but no more than 150%
in Household 75%of FPG or Less 100%FPG 125%FPG FPG
9 $ 41,774 $ 41,775 $ 55,700 $ 55,701 $ 69,625 $ 69,626 $ 83,550
T
10 $ 45,629 $ 45,630 $ 60,840 $ 60,841 $ 76,050 $ 76,051 $ 91,260 a
co
11 $ 49,484 $ 49,485 $ 65,980 $ 65,981 $ 82,475 $ 82,476 $ 98,970 m
12 $ 53,339 $ 53,340 $ 71,120 $ 71,121 $ 88,900 $ 88,901 $ 106,680 o
-
13 $ 57,194 $ 57,195 $ 76,260 $ 76,261 $ 95,325 $ 95,326 $ 114,390 m
14 $ 61,049 $ 61,050 $ 81,400 $ 81,401 $ 101,750 $ 101,751 $ 122,100
15 $ 64,904 $ 64,905 $ 86,540 $ 86,541 $ 108,175 $ 108,176 $ 129,810 c
16 $ 68,759 $ 68,760 $ 91,680 $ 91,681 $ 114,600 $ 114,601 $ 137,520 m
17 $ 72,614 $ 72,615 $ 96,820 $ 96,821 $ 121,025 $ 121,026 $ 145,230 5
18 $ 76,469 $ 76,470 $ 101,960 $ 101,961 $ 127,450 $ 127,451 $ 152,940 v
19 $ 80,324 $ 80,325 $ 107,100 $ 107,101 $ 133,875 $ 133,876 $ 160,650 61
20 $ 84,179 $ 84,180 $ 112,240 $ 112,241 $ 140,300 $ 140,301 $ 168,360
LIHEAP $1,000(up to$1,350) $750(up to$1,100) $550(up to$900) $400(up to$750)
HOME ENERGY (Bose$1,000 plus one each of additional (Base$750 plus one each of additional assistance (Bose$550 plus one each of additional assistance (Bose$400 plus one each of additional assistance
BENEFIT' assistance below•') below•') below") below")
"Additional Assistance if applicant household includes any of the following: 'These benefit levels are effective July 1,2023.
(1)Elderly(Senior 60 and over) $100
Figures are based on the FY 2023 U.S.Department of
(2)Disabled $100
Health and Human Services(HHS)Guidelines published
(3)Child age 5 or younger: $150 in the Federal Register on January 19,2023.
t Maximum Income Values
are the greater of 60%SMI
(family size 1-8)or 150%FPL
(family size 9-20).
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ATTACHMENT XVII
EHEAP APPLICATION AND ELIGIBILITY WORKSHEET
Emergency Home Energy Assistance for the Elderly Program - Application
Section One: Applicant (Aged 60 and older) Information
Name: (First, M,Last) ❑ EHEAP ❑ Heating Season ❑Cooling Season
Date of birth: Age: SSN:
Service address: City: Date Stamp
Florida County: Zip Code: Phone: Intake worker's name:
Gender: ❑ Male❑ Female Number of people in the household:
Marital Status: ❑ Married ❑ Partnered ❑ Single ❑ Separated ❑ Divorced ❑Widowed Phone:
Race: ❑White ❑ Black/African American ❑Asian ❑ Native Hawaiian/Pacific Islander ❑American Indian/Alaska Native ❑ Other
Ethnicity: ❑ Hispanic/Latino ❑ Other Primary Language: ❑ English ❑ Spanish ❑ Other
Does client have limited ability reading,writing, speaking, or understanding the English language? ❑Yes ❑ No
Is the client a veteran? ❑Yes ❑ No Was client referred to the local Veteran's Affairs office? ❑Yes ❑ No ❑
N/A
Applicant's income type(s): Applicant's monthly income amount:
Section Two: Additional Household Members Information
Name: Income type(s):
Age: SSN: Monthly income amount:
Name: Income type(s):
Age: SSN: Monthly income amount:
Name: Income type(s):
Age: SSN: Monthly income amount:
Name: Income type(s):
Age: SSN: Monthly income amount:
Section Three: Household Characteristics
Is there a child 5 years of age or younger in the household? ❑Yes ❑ No
If Yes, select all that applies: 0 0-2 years old ❑ 3-5 years old
Is there an individual with a disability in the household? ❑ Yes ❑ No
Is the applicant a U.S. citizen or an alien lawfully admitted for permanent residence? ❑Yes ❑ No
Is the applicant a homeowner? ❑Yes ❑ No
Does applicant live in government subsidized housing, such as Section 8? ❑Yes ❑ No
If yes, provide the complex name:
If yes, does the household receive an energy subsidy? ❑Yes ❑ No
Does applicant live in a student dormitory, adult family care home, or any kind of group living facility? ❑Yes ❑ No
If yes, provide the facility name:
Section Four: Heating and Cooling Information
Have you or any member of your household received energy assistance in the current season? ❑Yes ❑ No
If yes, provide the name of Agency:
What is the primary source of home heating?(select one) ❑ Electricity ❑ Natural Gas ❑ Propane ❑Wood/Coal ❑ Refillable
Fuels
Does household use supplemental heating source? 0 Electricity 0 Wood/Coal 0 N/A Q
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Air conditioning unit type?❑ Central A/C ❑Window/Wall A/C ❑ Fans LI Other—specify(including evaporative cooler)
Section Five: Energy Crisis Client Attestation and Signature
❑ Home cooling or heating energy source has been The information provided on this application, is to the best of my knowledge,
disconnected. (Life-Threatening) true and complete. I understand that priority in providing assistance will be
given to those households with the lowest income and greatest need, i.e.
❑ Unable to get delivery of fuel, is out of fuel, or is those households in which the elderly, disabled, medically needy, or children
in danger of being out of fuel for heating. (Life- reside. I authorize the agency to make benefit payments directly to my
Threatening) energy supplier. I am aware that after I have provided all the information
❑ Other problems with lack of cooling or heating in requested to determine my eligibility, if I am applying for crisis assistance,the
the home, such as needing to pay a deposit, repair agency has 18 hours to act upon my application with an eligible action. I am
of equipment, or interim emergency measure to also aware that if I am not approved or denied within the time allowed, or not
avoid further crisis. (Life-Threatening) approved for the correct amount, I have a right to appeal the decision. (If you
sign with an"X"two witnesses are required.)
❑ Notified that the energy source for cooling or
heating is going to be disconnected. (Standard)
Client Signature:
❑ Received a notice indicating the energy source
bill is delinquent or past due. (Standard)
Date:
❑ Has an energy source bill for which the due date
has lapsed. (Standard)
ALL CLIENTS SHOULD SIGN THE WAIVER,AUTHORIZING THE RELEASE OF GENERAL AND/OR CONFIDENTIAL INFORMATION FOR LIHEAP/EHEAP FEDERAL REPORTING.
*Your Social Security Number(SSN)is confidential under law.We may not collect your SSN unless we explain the reason for collecting your SSN in
writing and provide the applicable statutory authority for doing so.Certain provisions of Chapter 430,Florida Statutes,read with Section 119.071(5),
Florida Statutes,specifically authorize the Department of Elder Affairs(DOEA)and its designated staff/employees to collect SSNs when authorized by
law or when collection of SSNs is imperative to the performance of DOEA's statutorily assigned duties.The Department is collecting your social
security number as part of its responsibility to provide Emergency Home Energy Assistance.
DOEA Form 114—07/01/2023
Emergency Home Energy Assistance for the Elderly Program - Eligibility Worksheet
Section Six: Income Eligibility Determination
Annualize all Staple calculator tape State Median Income(SMI)Guidelines
household income. here showing income effective 07/01/2023.
calculations or write
1. Add all gross calculations in this
monthly earned space.
and unearned
income from the
past 30 days of all Select the annual income limit by household size:
household 100%of Max Income Value(MIV) 50%of MIV
members.
2. Add Medicare ❑ 1 $27,735 $13,868
Premium ❑2 $36,269 $18,135
($148.50), if not ❑3 $44,803 $22,402
included in SSA ❑4 $53,337 $26,669
amount. ❑5 $61,870 $30,935
3. Add Medicare Part ❑6 $70,404 $35,202
D, if applicable. ❑7 $72,004 $36,002
4. To annualize, ❑8 $73,605 $36,803
multiply the (Please refer to the Federal Poverty Guidelines(FPG)Benefits Matrix for income
monthly total by 12 ranges for households with 9-or-more individuals.)
months.
Annual Household
Income
If the total annual household income is less than 50%of the current State Median Income for household size(using chart
❑ Categorically above),and no one in the household is receiving SNAP assistance,the applicant must provide a signed statement of how
Eligible basic living expenses(i.e.,food,shelter and transportation)are provided for the household.
Section Seven: Vendor, Benefit, and Verification Information
Energy Vendor#1 Other Vendor#1 Contact made with LIHEAP provider to verify previous crisis assistance.
Name: Name: Contact Person: 0
G6'
16Q3
AccountNo Date of contact:
Account Number: ucher Date: Has the applicant received LIHEAP crisis assistance during the current season?
Minimum Amount Amount ID Yes ID No
Due: Due:
Verification and ❑ ❑ Repair Existing
Commitment Blanket Heating or Cooling
❑ Equipment If the minimum amount due is more than the past due amount, did the
Contact Person: Portable ❑ Emergency energy vendor verify that this amount is required?
Fan Shelter ❑Yes ❑ No ❑ N/A
Energy Vendor#2 Other Vendor#2
Name: Name:
AccountNo
Account Number: ucher Date:
Number:
Minimum Amount Amount If the minimum amount due to resolve the crisis is more than the
Due: Due: maximum allowed, explain how the balance of the amount due will be paid
if approved for EHEAP crisis assistance.
Verification and ❑ ❑ Repair Existing
Commitment Blanket Heating or Cooling
❑ Equipment
Contact Person: Portable ❑ Emergency
Fan Shelter
(1)Total Energy $ (4)Total Other $
Vendors Vendors
(2) Energy Subsidy $ Total EHEAP Is the name on the fuel bill that of the applicants?
Benefit ❑Yes ❑ No
(3) Water,Sewer, Add If no, provide name on bill:
Garbage,Fire, $ Total Energy $
etc. Vendor(4)&
(4) Deduct(2&3) Total Other
from(1) $ Vendor(4)
Section Eight: Weatherization Assistance Program (WAP) Referral
If the applicant is a homeowner, has he/she received more than three LIHEAP or EHEAP benefits in the last 18 months?
❑Yes ❑ No ❑ N/A
If the answer to the previous question is"yes",was the applicant referred to WAP? ❑ Yes ❑ No ❑ N/A
If the answer to the last question is"no",
explain:
Section Nine: Resolution of Crisis
Resolution of the Heating/Cooling Energy Crisis occurred within 18/48 hours, by the following eligible action(s): (Select all that apply)
❑Approval of application ❑ EHEAP benefit prevented disconnection
❑ Commitment made to vendor ❑ EHEAP benefit restored energy already disconnected
❑ Denial of Application, pending ❑ Yes, client signed waiver
❑ Denial of Application, ineligible ❑ No, client refused to sign waiver
❑Written referral and assistance to access other community resources
Case Worker Signature Approval Signature
have determined the eligibility of the The application and eligibility determination must be reviewed for errors and appropriate file
applicant. I am not the applicant,nor am I a documentation prior to making payment. I have reviewed and approved this application for
friend,relative,or employee of the applicant. crisis assistance.
Case Worker's Name: Supervisor/Peer's Name:
Case Worker's Signature: Supervisor/Peer's Signature:
Date: Date:
Agency Name: Agency Name:
DOEA Form 114—07/01/2023 0
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Emergency Home Energy Assistance for the Elderly Program—Spanish Application Form
Seccion uno: Informacion del aplicante (60 anos o mas)
Nombre:(Nombre,segundo nombre,apellido) ❑EHEAP
❑Temporada caliente ❑Temporada
fria
Fecha de nacimiento: Edad: Numero Seg.Soc:
Direccion de servicio: Sello o registro de la fecha
Ciudad: Condado: Codigo postal: Nombre del trabajador:
Sexo: 0 M ❑ F Numero de personas en el hogar: Telefono:
Estado Civil: ❑Casado/a ❑Conviviente ❑ Soltero/a ❑Separado/a 0 Divorciado/a ❑Viudo/a Telefono:
Raza:0 Blanca❑ Negra/Afro-americana 0 Asiatica❑ Nativo de Hawai/Islas del Pacifico 0 Indio americano/Nativo de Alaska 0 Otro
Etnicidad: ❑ Hispano/Latino❑Otro Lengua materna: ❑ingles❑espanol 0 otro
AEI cliente tiene limitaciones para leer,escribir,entender o hablar el ingles? 0 Si❑ No
AEI cliente es veterano? 0 Si❑ No t,El cliente ha sido derivado a la Oficina de Asuntos del Veterano? 0 Si❑ No 0 N/A
Tipo(s)de ingreso(s)del solicitante: Ingreso mensual del solicitante:
.eccion dos: Informacion sobre otros miembros en el hogar
Nombre: Tipo(s)de ingreso:
IEdad: Numero de SS: ICantidad de ingreso mensual:
Nombre: Tipo(s)de ingreso:
IEdad: Numero de SS: ICantidad de ingreso mensual:
Nombre: Tipo(s)de ingreso:
lEdad: Numero de SS: ICantidad de ingreso mensual:
Nombre: Tipo(s)de ingreso
Edad: Numero de SS: Cantidad de ingreso mensual:
•eccion tres: Caracteristicas de los miembros del hogar
ZHay un nino menor de 5 anos en el hogar? ❑Si 0 No
De ser afirmativo,seleccione las que apliquen: 0 0-2 anos de edad 0 3-5 anos de edad
aExiste alguna persona con discapacidades en el hogar? 0 Si❑ No
i El solicitante es ciudadano estadounidense o extranjero con una residencia permanente? 0 Si❑ No
zEl solicitante es dueno de la vivienda?0 Si ❑ No
aEl solicitante vive en una vivienda subsidiada por el gobierno,tal como Section 8? 0 Si❑ No
Si es afirmativo,provea el nombre del complejo
habitacional:
Si
iEl solicitante vive en una residencia universitaria,hogar de cuidado familiar para adultos,o cualquier otro tipo de instalacion compartida? 0 Si
❑ No
Si es afirmativo,provea el nombre de la instalacion:
►eccion cuatro: Informacion sobre aire acondicionado y calefaccion
aHa recibido usted o algun miembro de su hogar ayuda con los servicios de electricidad en la temporada actual?0 Si 0 No
Si es afirmativo,provea el nombre de la agencia:
ZCual es la fuente principal de calefaccion domestica?(seleccione una) ❑ Electricidad 0 Gas natural ❑Gas propano
❑ Madera/carbon 0 Combustibles rellenables
AEI hogar utiliza una fuente de calefaccion suplementaria?0 Electricidad ❑ Madera/carbon 0 N/A O
1 6 03
Tipo de aire acondicionado❑A/C Central ❑A/C de ventana/pared ❑Ventiladores El Otros—especifique(tales como aire
acondicionado portatil)
•eccion cinco: Explicacion de la crisis de energia Certificacion y firma del cliente
El Se ha cortado la fuente de energia de la calefaccion o del aire La informacion proporcionada en esta solicitud es a mi leal saber y
acondicionado en el hogar.(Pone en peligro la vida) entender completa y verdadera.Tengo entendido que se dare prioridad de
brindar asistencia a los hogares con ingresos mas bajos y con mayor
❑ No se puede obtener el suministro de combustible, se ha necesidad,p.ej.aquellos hogares en los que residen personas mayores,
quedado sin combustible o corre el riesgo de quedarse sin discapacitados o ninos con necesidades medidas.Autorizo a la agenda
combustible para la calefaccion.(Pone en peligro la vida) realizar los pagos de prestaciones directamente a mi proveedor de energia.
0 Otros problemas relacionados con la falta de aire acondicionado o Si estoy solicitando asistencia de crisis de energia,soy consciente que
calefaccion en el hogar,tales como la necesidad de pagar una garantia, despues de haber proporcionado toda la informacion solicitada para
reparacion de equipos o una medida de emergencia provisional para determinar mi admisibilidad,la agencia tiene 18 horas para tomar las
evitar futuras crisis.(Amenaza la vida) medidas necesarias y adecuadas en cuanto a mi solicitud.Asimismo,tengo
❑Se le notified)que se va a desconectar la fuente de energia para el conocimiento que,si no me aprueban o deniegan dentro del plazo
aire acondicionado o calefaccion.(Estandar) establecido,o si nose me aprueba por la cantidad correcta,tengo derecho
a apelar la decision.(Si firma con una"X",se exige que haya dos testigos).
❑ Recibi6 una notificaciOn indicando que la factura de electricidad esta Firma del cliente:
atrasada o vencida.(Estandar)
Fecha:
❑Tiene una factura de electricidad cuya fecha de vencimiento ha
caducado.(Estandar)
TODOS LOS CLIENTES DEBEN FIRMAR LA EXENCION.AUTORIZANDO LA DIVULGACION DE INFORMACION GENERAL Y/O CONFIDENCIAL
PARA EL INFORME FEDERAL DE LIHEAP/EHEAP
*Su numero de seguro social (SSN) es confidencial en virtud de la ley. No podemos recolectar su SSN a menos que le
expliquemos por escrito la razon y le proporcionemos la autoridad legal correspondiente para hacerlo. Ciertas
disposiciones del Capitulo 430,articulo 119.071 (5)de las Leyes de Florida,autorizan especificamente al Departamento
del Adulto Mayor(DOEA)y a su personal/empleados autorizados recolectar los SSN cuando to autorice la ley o cuando
la recolecciOn del SSN sea imperativa para el desempeno de las funciones asignadas por ley del DOEA.El Departamento
recolecta su numero de seguro social como parte de su responsabilidad de proporcionar asistencia de emergencia
energetica en el hogar.
Hoja de admisibilidad del Programa de Asistencia de Emergencia Energetica en el Hogar para Adultos Mayores
Seccion seis: Determinacion de Ia admisibilidad de ingresos
Escriba los calculos en este espacio o engrape Gula del ingreso promedio del estado a partir del
Anualice todos los ingresos del hogar la cinta de papel de la calculadora aqui en 01/07/2023
1. Sumetodos los ingresos brutos donde se muestren los calculos de sus Seleccione el limite de ingresos anuales seem el
mensuales ganados y aquellos ingresos, tamano de la unidad familiar:
ingresos no salariales de los ultimos
30 dlas de todos los 150%maximo del valor de ingresos(MVI) 50%de MVI
2. Agregue la prima de Medicare ($ ❑1 $27,735 $13,868
148.50),si no este incluida en el monto 0 2 $36,269 $18,135
de los beneficios del 0 3 $44,803 $22,402
3. Agregue la Parte D de Medicare,si es ❑4 $53,337 $26,669
necesario. 0 5 $61,870 $30,935
4. Para anualizar,multiplique el total ❑6 $70,404 $35,202
mensual por 12 meses. 0 7 $72,004 $36,002
Ingreso anual del hogar 0 8 $73,605 $36,803
$ (Consulte la estructura de los indicesfederales de
pobreza(FPG)para conocer los rangos de ingresos
para hogares con 9 o mas personas).
Si el total ingreso anual del hogar es menor que el 50%de las guias actuales de ingreso promedio para el tamano de la
❑ Categaricamente unidad familiar(usando el cuadro anterior),y ninguna persona en el hogar recibe asistencia de SNAP,el solicitante debe
admisible proporcionar un documento firmado de como se proporcionan los gastos basicos diarios tales comp comida,vivienda y
transporte en el hogar.
Seccion siete: Proveedor, recta y verificacion de Ia informacion
Proveedor de energia#1 Otro proveedor#1 Contacto realizado con el proveedor
Nombre: Nombre: de LIHEAP para verificar la previa
asistencia de crisis de energia.
NOmero de cuenta/
Persona de contacto:
Numero de cuenta: comprobante: Fecha:
1603
Fecha de contacto:
Importe minimo adeudado: Cantidad adeudada:
iEl solicitante ha recibido
asistencia de crisis de energia de
LIHEAP durante la temporada
actual?❑SI ❑ No
Verification obligaciones Persona de ❑Mantas ❑Reparacion de equipos de
y g calefaccion o aire acondicionado Si el importe minimo adeudado
contacto: Ventilador portatil existentes
Calefactor es mayor que la cantidad
❑ ❑Refugio de emergencia adeudada anterior,tel
Fecha: ❑A/C de ventanas ❑Otros: proveedor de energia verifico
que se requiera ese monto?
Proveedor de energia#2 Otro proveedor#2 ❑Si ❑ No ❑ N/A
Nombre: Nombre:
Numero de cuenta/
Numero de cuenta: comprobante Fecha: Si el importe minimo adeudado
para solucionar la crisis es
mayor que el maxima
Importe minimo adeudado: cantidad adeudada: permitido,explique coma se
pagara el saldo del monto
adeudado si es aprobado para
la asistencia de crisis de
EHEAP.
0 Mantas 0 Reparacion de equipos de
VerificaciOn y obligaciones Persona de calefaccion a aire acondicionado
❑Ventilador portatil existentes
contacto: ❑Calefactor ❑Refugio de emergencia
Fecha: ❑A/C de ventanas ❑Otros:
(1)Totaldel proveedor/es de energia El nombre que figura
$ (4)Total de otros proveedores $
en la factura de
(2)Subsidio de energia $ combustible es el del
solicitante?
(3)Agua,alcantarillado,basura, $ Renta total de EHEAP Sume el ❑Si ❑ No
fuego,etc. total del proveedor de energia(4)y
$ Si es no,proves el nombre
el total de otros
proveedores(4) de la persona que figura
(4) Deducible(2&3)de(1) $ en la factura:
Seccion ocho: Referencia del Programa de Asistencia para Climatizacion (WAP)
Si el solicitante es propietario de la vivienda,cha recibido mas de tres beneficios de LIHEAP o EHEAP en los ultimos 18 meses?
❑ Si❑ No❑ N/A
Si la respuesta a la pregunta anterior es"Si",i.el solicitante obtuvo una referencia de WAP?0 Si 0 No 0 N/A
Si la respuesta a la ultima pregunta es"No",explique:
Seccion nueve: Solucion de la crisis
La solucion de la crisis de calefaccion o aire acondicionado se produjo dentro de las 18/48 horas,mediante las siguientes acciones adecuadas:
(Seleccione todas las que correspondan)
❑Aprobacion de la aplicacion ❑ Los beneficios de EHEAP evito la desconexion
❑ Compromiso hecho con el proveedor 0 Los beneficios de EHEAP restauro la energia cortada
❑Aplicacion denegada,informacion adicional pendiente 0 Si,el cliente firma la exencion
❑Aplicacion denegada,no cumple con los requisitos 0 No,el cliente se nee a firmar la exencion
❑ Obtuvo una referencia por escrito y ayuda para acceder a otros servicios de la comunidad tLO
! 603
Firma del encargado/a del caso Firma de aprobacion
La determinacidn de la aplicaciOn y de admisibilidad deben revisarse para
He determinado la admisibilidad del solicitante.No soy el solicitante,ni su amigo, detectar errores,y la documentacibn adecuada debe estar en archivo
pariente o empleado del solicitante. antes de realizar el pago.He revisado v aprobado esta solicitud de
asistencia de crisis de energia.
Nombre del encargado/a del caso: Nombre del supervisor:
Firma del encargado/a del caso: Firma del supervisor:
Fecha: Fecha:
Nombre de la agenda: Nombre de la agenda: