Summer Cooling Assistance Program (SCAP) Application

Please List All Household Members

List YOURSELF first:
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Age:*
Social Security Number:*
What is your race?*
Sex:*
Do you have a disability?*
Citizenship Status:*
What is your MONTHLY INCOME?*
Are there additional household members to add?*

YesNo

Household Member #2 Full Name:*
Date of Birth:*

MonthDayYear
Date
Age:*
Social Security Number:*
Relationship to YOU:*
What is this person's race?*
Sex:*
Does this person have a disability?*
Citizenship Status:*
What is this person's MONTHLY INCOME?*
Are there additional household members to add?*

NoYes

Household Member #3 Full Name:*
Date of Birth:*

MonthDayYear
Date
Age:*
Social Security Number:*
Relationship to YOU:*
What is this person's race?*
Sex:*
Does this person have a disability?*
Citizenship Status:*
What is this person's MONTHLY INCOME?*
Are there additional household members to add?*

YesNo

Household Member #4 Full Name:*
Date of Birth:*

MonthDayYear
Date
Age:*
Social Security Number:*
Relationship to YOU:*
What is this person's race?*
Sex:*
Does this person have a disability?*
Citizenship Status:*
What is this person's MONTHLY INCOME?*
Are there additional household members to add?*

YesNo

Household Member #5 Full Name:*
Date of Birth:*

MonthDayYear
Date
Age:*
Social Security Number:*
Relationship to YOU:*
What is this person's race?*
Sex:*
Does this person have a disability?*
Citizenship Status:*
What is this person's MONTHLY INCOME?*
Are there additional household members to add?*

YesNo

Household Member #6 Full Name:*
Date of Birth:*

MonthDayYear
Date
Age:*
Social Security Number:*
Relationship to YOU:*
What is this person's race?*
Sex:*
Does this person have a disability?*
Citizenship Status:*
What is this person's MONTHLY INCOME?*
Are there additional household members to add?*

YesNo

Household Member #7 Full Name:*
Date of Birth:*

MonthDayYear
Date
Age:*
Social Security Number:*
Relationship to YOU:*
What is this person's race?*
Sex:*
Does this person have a disability?*
Citizenship Status:*
What is this person's MONTHLY INCOME?*
Are there additional household members to add?*

YesNo

Household Member #8 Full Name:*
Date of Birth:*

MonthDayYear
Date
Age:*
Social Security Number:*
Relationship to YOU:*
What is this person's race?*
Sex:*
Does this person have a disability?*
Citizenship Status:*
What is this person's MONTHLY INCOME?*

Additional Documentation

Please upload required documents here:
Identification: Please upload a CLEAR and CURRENT Photo ID for each household member over the age of 18.*

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Social Security Cards: Please upload SS Cards for all household members over 6 months of age:*

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Proof of Income: Please provide pay stubs for each household members over the age of 18 who have earned income. If you are self-employed, please provide a copy of your most recent filed tax return (1040 & ALL Schedules); All other income types: Social Security, SSI, Veteran's Assistance Award Letter or bank statement showing direct deposit amount; proof of pension. Variable income: Paystubs for the last 3 months or year-to-date pay stub. Proof of Unemployment payments, child support, TANF/GA.*

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Proof of Citizenship: For US Citizens: birth certificate, passport/passport card, Native American Tribal Card, Certificate of Naturalization; certificate of citizenship*

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Proof of Qualified Alien Status: Lawful permanent resident, cross border NA Indian, asylee, refugee, Cuban/Haitian entrant, paroled in to the US for at least one year; deportation being withheld; battered immigrant spouse/children; victim of trafficking; members of armed services or veterans.*

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Utilities: Please upload a copy of your most recent electric bill:*

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I certify that I have checked the information on this application and that it is true and correct to the best of my knowledge. I agree to notify the agency of any changes to this application within ten (10) days. I certify that this is the only application submitted from or on behalf of my household. I understand this application will not be completed until ALL necessary documents have been received. If those documents are not received within thirty (30) days, this application will be void. I understand that it is against the law to make false statements and that I am subject to prosecution if I do. I understand my right to a fair hearing if I am dissatisfied with the application process or eligibility decision. I authorize the agency to refer my application to programs within state agencies as deemed beneficial to my household. I authorize the Department of Health & Social Services (DHSS) and its LIHEAP service providers to obtain information about my utility usage and billing history from my vendor(s). I am the customer fo record, customer's authorized agent or an authorized third party for the energy service account identified in this application and I authorize my energy service provider to disclose my customer data.
Applicant Signature:*
Date:

MonthDayYear
Date
IMPORTANT!

BEFORE you click SUBMIT, please PREVIEW your form to ensure everything is correct! If you are a RENTER, please PRINT the form and have your landlord complete the Authorization Form. Email or scan this form to scap@firststatecaa.org. If you are declaring ZERO INCOME, please print and sign the Zero Income Declaration form and return to scap@firststatecaa.org.
Should be Empty:

Summer Cooling Assistance Program (SCAP)

Information about you and your family

Please List All Household Members

Information about your home

Energy Survey

Thank You For Participating in this Survey!

Additional Documentation

IMPORTANT!