LIHEAP Form

"*" indicates required fields

Full Legal Name*

Social Security Number*

Address*

Street Address Address Line 2 City County Zip Code

Email*

Enter Email Confirm Email

Are you currently without services?*

Yes

No

What type of documents are you uploading? (select all that apply)*

Full completed LIHEAP application

Copy of social security card for one, or more, household members

Income documents (wage documentation form, Low Income Interview Guide, pay stubs, Social Security benefits award letter, termination letter, etc)

Additionally requested documents in a letter you received from the CMCA Energy Department

Landlord form

Copy of utility bill(s)

Copy of Non-Energy Form & Receipt

Change of address application

Change of utility company application

Change of household member application

Other (please specify)

Please specify what other documents you plan to upload.*

Attach your documents

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Attach your documents

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Add your files

Format: JPG • PDF • DOC • DOCX • JPEG

Maximum size: 4 MB

Files

Terms*

I understand that this form I completed today is not the LIHEAP application.

I understand that this form I completed today is not the LIHEAP application. If you need to complete the LIHEAP application, please submit directly through the DSS online form.

Central Missouri Community Action
807 N. Providence Rd.
Columbia, MO 65203

573-443-8706 | Fax (573) 875-2689

Email: pr@cmca.us

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