Includes links to forms, spreadsheets and sample letters that Service Providers need to manage the EAP program. These online documents allow you to save, add Service Provider identification, complete and print the forms electronically. Click on the hyperlinked text for a particular section to "jump" to the related forms.
Entering Application Information in eHEAT (.pdf)
This document provides guidance, including eHEAT screen shots, for entering applications information into eHEAT.
FFY14 Application Requirements Tool (.pdf)
This document provides guidance about what application information must be obtained from the EAP household and which information can be obtained from other sources (e.g. prior year eHEAT information, energy vendor disconnect notice, etc.) Highlighted textboxes indicate required information.
Address Standards (Appendix 4C) (.pdf)
Details on address standards to reduce the entry of duplicate addresses into eHEAT and prevent potential errors and fraud. If a standard is not listed in Appendix 4G, additional guidance can be found at the U.S. Postal Service website.
Authorized Alternatives to SSN (Appendix 5G) (.pdf)
This lists the authorized alternative documents acceptable in place of the Social Security Number (SSN) for the primary applicant for EAP eligibility.
Safe at Home Participant Instructions (Appendix 4B) (.pdf)
These instructions aid Safe at Home participants in completing the EAP Application without compromising their safety.
Language Line Information (Appendix 2A) (.pdf)
This explains the Language Line services available for use by EAP Service Providers.
Statewide Information and Referral Services (Appendix 2B) (.pdf)
This explains the 211 statewide information referral services.
Income Inclusions and Exclusions (Appendix 5A) (.pdf)
This table details the type of income included and excluded for EAP eligibility determination.
Self-Employment Income (Appendix 5B) (.xls)
Use the Excel worksheet to determine income and expenses from self-employment.
Self Employed Worksheet Cash Accounting Method (Appendix 5C) (.xls)
Use this Excel worksheet to determine income and expenses for rental property and new businesses.
Self Employed Worksheet Farm Cash Accounting Method (Appendix 5D) (.xls)
Use the Excel format worksheet for new farming operations.
Social Security Benefits Worksheet (Appendix 5F) (.doc)
Use this Word worksheet to determine SS and SSI benefits based on past years’ documentation.
Online Income Documentation (.pdf) (Appendix 5H)
This details how households can obtain online Social Security income and Unemployment Insurance income documentation.
Sample UI Screens (.pdf)
Shows how UI recipients navigate the Unemployment Insurance (UI) website to gather UI benefit information for EAP.
Mail Return Service Requested (Appendix 10A) (.pdf)
This explains the postal service format an SP should use to mail the letter requesting information about a household move that will result in the SP receiving information that the household has moved and, if available, the new address.
Affidavit of Failure to Receive MMB Warrant (Appendix 10C) (.doc)
This form is completed and submitted to Minnesota Management & Budget if a household fails to receive a direct payment that was issued to them by EAP.
Handling Payments and Refunds in eHEAT when a Household Moves (Appendix 10E) (.pdf)
The vendor refunds any remaining EAP benefit in eHEAT so the Service Provider can re-direct the payment to the household's new vendor.
Weekly Application Certification Targets (WACT) (Appendix 4A) (.pdf)
This table provides a guideline for the number of approved applications Service Providers should process before the 30-day requirement is in effect. LIHEAP requires applications receive timely service and WACT is used as a tool to assess this. WACT goes into effect at the end of the day on October 4, 2013.
Assurance 16 Proposal (Appendix 9A) (.doc)
Service Providers use this form to propose activities that do not fit in the categories for referral and advocacy already defined in the FFY14 EAP Policy Manual, Chapter 9.)
Report on Proposed A16 Activities (Appendix 9B) (.doc)
Service Providers must use this form to report on the results of their approved A16 Proposal. Reports for approved FFY14 Service Provider A16 proposals are due by June 16, 2014. DOC may request reports at other points if necessary (e.g., if an activity is initiated after June 16).
A16 & Outreach Activities Report (Appendix 9C) (.doc)
Service Providers must use this form to report on their A16 and Outreach activities to demonstrate program impact, maintain accountability, and identify best practices. This report is due by June 16, 2014. Proposed activities should not be included in this report; they should be included in Appendix 9B.
Reasonable Payment Worksheet (RPWS) (Appendix 9D) (.xls)
Use the Excel worksheet to determine a household's minimum "Reasonable Payment" to their energy vendors.
Understanding FFY14 Assurance 16 Changes (.pdf)
This document provides basic background and guidance on the following:
Biofuel Worksheet (Appendix 6C) (.xls)
Use this Excel document to determine the average cost for biofuel (wood, corn, pellets) when documentation of actual cost is not available
Letter for Information About Household Move (Appendix 10B) (.doc)
Use the MS Word format template to correspond with households whose benefit has been returned by a vendor because they moved.
These are examples of the EAP letters generated through eHEAT. Examples include Notification, Request for Information, and Denial Letters.
Energy Vendor Monitoring Report Cover Letter (Appendix 3B) (.doc)
Energy Vendor Monitoring Report (Appendix 3C) (.doc)
Use the MS Word form to document vendor monitoring by Service Providers.
FFY2014 Agreement Between Energy Vendor and Service Provider (Appendix 3A) (.doc)
Agreement outlining the interaction between EAP vendors and Service Providers to assure understanding.
Energy Vendor Registration Form for EAP Payment (.doc)
To receive payments through the Energy Assistance Program (EAP) an energy vendor must register with the Minnesota Energy Assistance Program by completing this form. This also registers vendors for eHEAT.
FFY2014 EAP Policy Manual Chapter 3 - Energy Vendors (.pdf)
Chapter 3 is from the FFY2013 EAP Policy Manual and contains most of the primary policies for EAP vendors.
W-9 Form (website)
Energy vendors seeking to be included as vendor in eHEAT and receive payments from the Energy Assistance Program must now submit to the Department of Commerce a completed W-9 Request for Taxpayer Identification Number and Certification Form which can be downloaded from the U.S. Internal Revenue Service by clicking on the W-9 Form link above.
Crisis Fuel - Post Delivery Verification Form (.doc)
This form is used to obtain energy vendor Crisis fuel post-delivery information when all necessary information is not otherwise obtained by phone, email, fax or delivery slip. Service Providers may not edit the content of this form; however, when necessary, can use the "Additional Information" box for information unique to the energy vendor they are working with. The Service Providers can use this box to communicated questions or information regarding or for the purpose of obtaining program requirement only.
EAP Contract FFY2014 (Appendix 15A) (.pdf)
The Low Income Home Energy Assistance Program Grant Contract (also referred to as the EAP Contract) serves as the written agreement between the DOC and all Service Providers who deliver EAP services.
Certifications Regarding Lobbying; Debarment, Suspension and Other (Appendix 15B) (.pdf)
Signature of this form provides for compliance with certification requirements.
Service Provider Out of State Travel Request Form (Appendix 16F) (.doc)
Requests must be submitted to email@example.com at least one month prior to travel using this form. The Service Provider must specify how much of the total travel cost will be paid for with EAP funds. If non-EAP funds will be used, identify the other fund sources and the amounts.
Local Level Formal Appeals - Required Tracking Sheet (Appendix 12B) (.doc)
Must be used by Service Providers to track all local level formal appeals and updates as they occur. The department may request this information at any time.
Incident Report Form (Appendix 12A) (.doc)
Use the MS Word form to report unusual circumstances or misspent EAP funds due to fraud or error.
Energy Programs Service Provider eHeat Administrator Security Agreement (Appendix 13C) (.pdf)
This document is signed by eHEAT Security Administrators to ensure understanding of data practices.
Energy Programs Service Provider eHeat
User Security Agreement (Appendix 13D)
This document is signed by eHEAT users to ensure understanding of data practices. It is available as a Word.doc or as a .PDF file.
Informed Consent for Release of Data Form (Appendix 13A) (.pdf)
This form authorizes release of information collected, maintained, or created by the Energy Assistance Program. This Consent is needed to verify what specific private data to release and to protect.
Debtors Exemption Claim Notice Example (Appendix 13B) (.doc)
Template for Garnishment Response Letter (Appendix 13E) (.doc)
This sample letter is provided to help Service Providers respond to garnishment information requests.
ERR Forms (Appendix 8A) (.xls)
The ERR Completion Certificate, Replacement Inspection Tool, and Troubleshooting Tool are combined in one Excel workbook with the capacity to populate all forms at once with household data downloaded from eHEAT.
Crisis Eligibility Decision Chart (Appendix 7A) (.pdf)
This chart guides Service Providers in determining if a household is eligible for a Crisis benefit.
Initial Program Assessment Guide (iPAG) (.doc)
Service Provider completes the guide and provides it to the DOC Program Performance Auditor (PPA) at time of Initial Program Audit Visit (iPAV).
Service Provider EAP Program Audit Disclosure Letter (Appendix 17A) (.doc)
Service Providers submit the Disclosure Letter within one week after completion of the DOC annual onsite full monitoring visit.
Full Program Audit Tool (fPAT) (.pdf)
EAP Program Coordinators complete the Full Program Audit Tool just prior to the Full Audit Visit from their Program Performance Auditor. The fPAT assists EAP in identifying, reviewing and evaluating Service Provider performance in major areas of compliance.
Required and Optional EAP Forms (.doc)
This document formally details which EAP forms are required and which are optional for use by Service Providers.
Service Provider Purchase/Disposition Request (Appendix 16E) (.doc)
This MS Word document is the mechanism to obtain DOC approval for purchase or disposition of non-expendable personal property
Request For Additional ERR Funds (Appendix 16B) (.xls)
Use the Excel format to request ERR funds when the allocation is depleted.
Expenditure Detail Report (Appendix 14B) (.xls)
Use the Excel format worksheet as part of the final closeout package.
Notice of Funds Available (NFA) (Appendix 16A) (.pdf) The NFA lists the maximum dollar amounts the Service Provider may expend for certain types of budget categories, such as administration, Assurance 16 and ERR.
eHEAT Cash Request Screen Shot (Appendix 16C) (.pdf)
This shows the eHEAT screen used for executing cash requests.
Audit Report Schedule (Appendix 16D) (.pdf)
This lists the audit report submission due dates for each EAP Service Provider.
Service Provider/Non-profit/Community Partner Leveraging Survey Form (.doc)
Survey to report FFY2013 discounts and/or other benefits provided to low-income households to help with their energy bills.
Delivered Fuel Vendor Leveraging Survey Form (.doc)
Survey to report FFY2013 discounts and/or other benefits provided to low-income households to help with their energy bills.
Connected Utility Leveraging Survey Form (.doc) Survey to report FFY2013 discounts and/or other benefits provided to low-income households to help with their energy bills.
Leveraging Tracking Form (Appendix 14C) (.xls)
This optional form may help track EAP leveraging benefits so it easier to report on next year's Leveraging Survey.
FFY2014 EAP Local Plan Form (.doc)
This document is completed by EAP Service Providers as part of their contract to delivery EAP services.
FFY2014 EAP Local Plan Section 2.0 Risk Assessment Instructions (.pdf)
These instructions provide guidance to EAP Service Providers for completing the Risk Assessment Section (2.0) of the EAP Local Plan.