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.
Information on application processing.
Entering Application Information in eHEAT (.pdf)
This document provides guidance, including eHEAT screen shots, for entering applications information into eHEAT.
Address Standards (Appendix 4G) (.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 5H) (.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 4F) (.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.
Inadequate Income Worksheet (Appendix 5E) (.doc)
(Appendix 5E – in Spanish) (.doc)
Use the English or Spanish version of this MS Word form to document households claiming no income.
Sample Eligibility Worksheet (Appendix 5F) (.doc)
Use the MS Word form as an option for determining total household income when income is not detailed in eHEAT.
Social Security Benefits Worksheet (Appendix 5G) (.doc)
Use this Word worksheet to determine SS and SSI benefits based on past years’ documentation.
Sample UI Screens (.pdf)
Shows how UI recipients navigate the Unemployment Insurance (UI) website to gather UI benefit information for EAP.
2013 Benefit Tables - (Appendix 6A & 6B)
Cost-Based Matrix | Back-Up Matrix (.pdf)
Matrices of EAP Benefit Tables used to calculate benefit amounts.
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.
Flow Chart for Vendor has EAP Money to Return (Appendix 10B) (.pdf)
This chart helps to determine if a vendor's EAP refund should go to the household or be returned to the EAP program.
Affidavit of Failure to Receive MMB Warrant (Appendix 10D) (.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 10F) (.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 4E) (.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 5, 2012.
Information on heating cost forms.
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 HH Move (Appendix 10C) (.doc)
Use the MS Word format template to correspond with households whose benefit has been returned by a vendor because they moved.
Information on assurance 16 forms.
Reasonable Payment Worksheet (RPWS) (Appendix 9A) (.xls)
Use the Excel worksheet to determine a household's minimum "Reasonable Payment" to their energy vendors.
Information on EAP notification
These are samples of some of the EAP letters generated through eHEAT. Samples include Notification, Request for Information, and Denial Letters.
Information on vendor management.
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.
FFY2013 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.
FFY2013 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.
Information and reporting to be submitted by providers.
EAP Contract FFY2013 (Appendix 15A) -- updated version coming soon
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 eap.mail@state.mn.us 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.
Information on data practices forms.
Energy Programs Service Provider eHeat Administrator Security Agreement (Appendix 13C) (.pdf)
This document is to be signed by eHEAT Security Administrators to ensure understanding of data practices.
Energy Programs Service Provider eHeat
User Security Agreement (Appendix 13D)
This document is to be signed by eHEAT users to ensure understanding of data practices. It is available as a Word.doc or you can download 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 (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.
Information on crisis and energy related repair forms.
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.
Information on monitoring forms.
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).
2012 Full Monitoring Tool (.pdf)
EAP Program Coordinators complete the Full Monitoring Tool just prior to the Full Monitoring Visit from their Field Representative. The FMT assists EAP in identifying, reviewing and evaluating Service Provider performance in major areas of compliance.
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.
Information on leveraging forms.
Service Provider/Non-profit/Community Partner Leveraging Survey Form (.doc)
Survey to report FFY2012 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 FFY2012 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 FFY2012 discounts and/or other benefits provided to low-income households to help with their energy bills.
Leveraging Tracking Form (Appendix 14D) (.xls)
This optional form may help track EAP leveraging benefits so it easier to report on next year's Leveraging Survey.
Information on planning forms.
FFY2013 EAP Local Plan Form (.doc)
This document is completed by EAP Service Providers as part of their contract to delivery EAP services.
FFY2013 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.
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