Byrd Barr Place Energy Assistance Application: 2024-2025 season

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Getting Started

This program cycle runs from Oct 1, 2024 - End of Summer '25
You MUST qualify for the standard LIHEAP grant using this application FIRST if you wish to receive any secondary benefits, such as an AC unit, or furnace repair.  You will be able to designate which secondary programs you would like to apply for later on in the application. 


*Please note that your application expires 90 days from the signature date and we are unable to process an application that is missing required documents, signatures, or information. We may also reach out to you requesting additional documents, information, or signatures.*


Please visit our website for important information such as Income Limits, Frequently Asked Questions, and a list of Required Documents you will need before you begin. 


Technical considerations before you begin:

  • There is a 35MB limit for all pictures & documents being uploaded.  This can be an issue if the images you're uploading are extremely high quality or if you live in a larger household. If you receive an error titled "REQUEST ENTITY TOO LARGE" for exceeding the maximum file size, please re-submit the application with only the uploads for your utility bill(s), and we will send you a secure upload link to attach your remaining documents separately.
  • Once you have uploaded a file from your device, you cannot change the filename on your device or the document will not be transferred.
  • For questions regarding how to answer a question on this form, please contact energyassistance@byrdbarr.place
  • For common technical issues, please take a look at our Frequently Asked Questions
All information collected is confidential and will only be used to deem eligibility for Byrd Barr Place's internal programs. 






***MUST BE IN _________@____.___ format. If you do not have an email address, please enter none@none.com







Before we get started, let's make sure you are in our service area

"Zip codes 98133 and 98177 are split zip codes and may require being served by a different agencies."

Unfortunately, we cannot provide services to households outside of Seattle City Limits.
Please visit the Department of Commerce's website to determine your Energy Assistance Provider

 

If you are located:

NORTH of Seattle

Hopelink


8990 154th Avenue Northeast
Redmond, Washington 98052
hopelink@hopelink.org

Appointments:
425.658.2592

SOUTH of Seattle

Multi-Service Center

203 SW 153rd Street
Burien, WA 98166
info@mschelps.org

Appointments:
253.517.2263
Online

Urgent Status?

If you have not received a shutoff notice and you are primarily interested in secondary programs, please select the top option.

* While not required at this time to formally submit an application, uploading documents that verify your answers will significantly reduce the amount of time your application will take to process and greatly increase the likelihood of being awarded a grant.*

* While not required at this time to formally submit an application, uploading documents that verify your answers will significantly reduce the amount of time your application will take to process and greatly increase the likelihood of being awarded a grant.*
Tell us about yourself!
Please note that you MUST be the individual named on your household's utility bill in order to apply as the Primary Applicant




*There is a 29-character limit; please abbreviate long names such as "Martin Luther King Jr Way South APT101" to "MLK Jr Way S #101" No periods or commas.



Street address only. Put city/state below. Please include Apartment/Unit #




No parentheses or dashes necessary.






You will still receive correspondence as required to process your application.
Tell us about your home!
Home type image






*****"Your grant will be paid to you by check unless you receive a utility bill in your name, which we will need to see below*****

*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*

  • If you pay Heat With Rent, your grant will come to you as a check to the address on your lease.
  • Your landlord will need to verify that you pay Heat With Rent
  • Please fill out as much of their information below as you can






***** IF YOU RECEIVE A GRANT IT WILL BE PAID AS A CREDIT ON YOUR UTILITY BILL FOR OIL, GAS OR ELECTRIC USERS. *****


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*

If you only have one energy provider, select None


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*

*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
Help us verify your identity

At least ONE (1) household member must have a Social Security Number to apply


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
Please note that the following are the forms of Social Security Number documentation that Byrd Barr Place will accept:

·       U.S. Social Security Card

If your Social Security card is missing or you can’t find a replacement for the Social Security card, here is a list of alternative documents that can be used. Please note that an additional document, such as a US birth certificate or US passport is also required when providing one of the alternatives below (Includes adults and minors currently living in the household).


·       W-2 Form with full SSN (including W-2C, W-2G, etc.)

·       SSA-1099 Form with full SSN (including SSA-1099-SM, SSA-1099-R-OP1, etc.)

·       Non-SSA 1099 Form with full SSN (including 1099-DIV, 1099-MISC, etc.)

·       1098 Form with full SSN (including 1098-C, etc.)

·       Bank, loan, or financial documents with full SSN

·       Paystub with full SSN


(MM/DD/YYYY) (09/09/1999) (must include leading 0s)








Tell us about your Income
Income limits are based on a monthly average per household, not per person* 

*Including Self-employment, TANF, SSI, Unemployment, etc.
Help us verify your income

*** You must enter a number greater than 1 for at least one of past three months for each income source you select.***
3 Month History - Supplemental Security Income (SSI)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Social Security Administration (SSA)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Pension (Retirement)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Earned Income (Paycheck/Salary)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*With Pay dates for the most recent month is REQUIRED at a minimum.  Providing All paystubs from the past 3 months will MAXIMIZE your grant amount. *




(may be needed if uploading individual bi-weekly stubs)

3 Month History - Self-Employed (Small Business/Freelance)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Unemployment

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Temporary Assistance for Needy Families (TANF)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - General Assistance (GA)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Veteran's Affairs (VA)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Military

Income


(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Child Support

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Other

Income

(Please round to nearest whole number, no "$" sign)

Income


Income



*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*

Please share with us why you have not received income in the last 3 months


Declaration of No Income
I do hereby declare that I have not received any income in the previous 3 months.
I certify that the information contained above is complete and accurate to the best of my knowledge. I understand that I will be giving my signature at the end of this form that will hold under penalty of prosecution. If I knowingly give false information which results in assistance, I may be denied future services.


Tell us about the members of your household


Please complete this section for each Household Member. 

All household members 18 or over must complete their own income section(s) acknowledging their income being counted. 

At the bottom of this page is an "Add another person" button that will allow you to repeat this section for each household member. 






(MM/DD/YYYY) (ex. 09/09/1999) (must include leading 0s)


All household members that are U.S. Citizens must provide a valid Social Security Number and documentation for a complete application.


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*  If you are unable to upload any documents, you can receive a 24-hour link to upload them as soon as possible.
Please note that the following are the forms of Social Security Number documentation that Byrd Barr Place will accept:

·       U.S. Social Security Card

If your Social Security card is missing or you can’t find a replacement for the Social Security card, here is a list of alternative documents that can be used. Please note that an additional document, such as a US birth certificate or US passport is also required when providing one of the alternatives below (Includes adults and minors currently living in the household).


·       W-2 Form with full SSN (including W-2C, W-2G, etc.)

·       SSA-1099 Form with full SSN (including SSA-1099-SM, SSA-1099-R-OP1, etc.)

·       Non-SSA 1099 Form with full SSN (including 1099-DIV, 1099-MISC, etc.)

·       1098 Form with full SSN (including 1098-C, etc.)

·       Bank, loan, or financial documents with full SSN

·       Paystub with full SSN









*Including Self-Employment, SSI, Pensions, etc.

*Providing this documentation will allow us to exclude your 18-year-old household member's income; without it, their income must be counted which will result in a lower grant amount.
Income Section

*** You must enter a number greater than 1 for each income source you select.***
3 Month History - Supplemental Security Income (SSI)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Social Security Administration (SSA)

Income

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Pension (Retirement)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Earned Income (Paycheck/Salary)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*



3 Month History - Self-Employed (Small Business/Freelance)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Unemployment

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Temporal Assistance for Needy Families (TANF)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - General Assistance (GA)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Veteran's Affairs (VA)

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Military

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Child Support

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
3 Month History - Other

Income

(Please round to nearest whole number, no "$" sign)

Income

Income


*These documents are REQUIRED for a valid application. We will allow a submission without uploading, but the application will not be considered complete until ALL verification documents are received.*
No Income Section

"School, out of work, etc."

"savings, family, etc."

BELOW IS A LIST OF SECONDARY PROGRAMS YOU MAY BE ELIGIBLE FOR:

Interested in additional assistance for Furnace Repair, Replacement or Cleaning?
We noticed that you are a homeowner:

Interested in Emergency Shelter Assistance?
We noticed that you are a renter:  Byrd Barr Place offers an Eviction Prevention program for renters who have received an eviction notice and are facing a heat-related crisis.   

Please be aware: (a) Byrd Barr Place has limited funds for rental assistance. (b) Applying does not guarantee assistance. (c) Your landlord’s cooperation is required.

Interested in an Air Conditioner (A/C) Unit?
LIHEAP now offers a once-per-lifetime benefit of receiving a portable A/C unit for eligible households. 

Please be aware: indicating interest does not guarantee a unit. We will reach out to you with additional terms if eligible.
Interested in an Air Purifier?
The LIHEAP Program now offers a once per lifetime benefit of receiving a portable Air Purifier unit for eligible households.

*The governor must first declare a state-wide emergency in order for us to purchase you a unit

Please be aware: indicating interest does not guarantee a unit. We will reach out to you with additional terms if eligible.
Do you have WATER or SEWER charges through SPU?
LIHWAP WATER ASSISTANCE PROGRAM
- Eligible LIHEAP households can apply for a grant of up to $2,500 to pay for water and sewer charges from Seattle Public Utilities (Water and Sewer Only)
- Note: this program ends at the end of March 2024




DSHS Consent Form









Consent

Notice to Clients: The Department of Social and Health Services (DSHS) can help you better if we are able to work with other agencies and professionals that know you and your family. By signing this form, you are giving permission for DSHS and the agencies and individuals listed below to use and share confidential information about you. DSHS cannot refuse you benefits if you do not sign this form unless your consent is needed to determine your eligibility. If you do not sign this form, DSHS may still share information about you to the extent allowed by law. If you have questions about how DSHS shares client confidential information or your privacy rights, please consult the DSHS Notice of Privacy Practices or ask the person giving you this form.

Consent

1. I consent to the use of confidential information about me within DSHS to plan, provide, and coordinate services, treatment, payments, and benefits for me or for other purposes authorized by law. I also grant permission to DSHS and the below listed agencies, providers, or persons to use my confidential information and disclose it to each other for these purposes. Information may be shared verbally or electronically, by mail, or hand delivery.
Reason for Disclosure: This information is required before DSHS can share drug and alcohol or mental health records. If you do not fill in this field, DSHS will note the reason for disclosure as being at your request. Please check all below who are included in this consent in addition to DSHS and identify them by name and address:



  • This consent is valid for one-year
  • I may revoke or withdraw this consent at any time in writing, but that will not affect any information already shared.
  • I understand that records shared under this consent may no longer be protected under laws that apply to DSHS
  • A copy of this form is valid to give my permission to share records.
Notice to Recipients of Information: If these records contain information about HIV, STDs, or AIDS, you may not further disclose that information without the client's specific permission. If you have received information related to drug or alcohol abuse by the client, you must include the following statement when further disclosing information as required by 42 CFR 2.32:

This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

Instructions for Completing the Consent Forms, DSHS 14-012

Use: Use this form when you need consent to use or share confidential information about a client on a continuing basis about a client within DSHS or to disclose that information to other agencies to coordinate services or for treatment, payment or agency operations or for other purposes recognized by law.

Fill out this form electronically if possible. You must complete a separate form for each person, including children..

Parts of Form:

IDENTIFICATION:
- Name: Provide the name of only one client on each form. Include any former names that client may have used when receiving services.
- Date of Birth: Needed to identify client from persons with similar names.
- Identification Number: Provide a client identification number or other identifier such as a social security number (not required) to assist in identifying records and tracking history and services received.
- Other: Include in this box any additional information that may help to locate records, such as DSHS involved with services, names of family members, or other relevant information.

CONSENT (AUTHORIZATION):
- Reason for disclosure: This information is required before DSHS can share drug and alcohol or mental health records. If you do not fill in this field, DSHS will note the reason for disclosure as being at your request.
- Agencies or persons exchanging records: This completed form allows: (1) the use and disclosure of confidential information inside DSHS and with the agencies or persons listed; and (2) disclosure of confidential information to DSHS by the outside agencies or persons listed. You may also attach a list of agencies allowed to share information, which the client must also sign.
- Information included: Clients must indicate what records are covered by the consent. Clients may make all records available or may limit the included records by date, type or source of record. If a client does not sign a consent or does not specify a particular record, sharing of that record will still be allowed if permitted by law. You may attach a list of covered records that the client must also sign. If any records include information relating to mental health (RCW 71.05.620), HIV/AIDS or STD testing or treatment (RCW 70.02.220), or drug and alcohol services (42 CFR 2.31(a)(5)), the client must mark these areas specifically to give permission to share these records. This form is not valid to include psychotherapy notes under 45 CFR 164.508(b)(3)(ii); a separate form must be completed to include those records.
- Duration: Include an expiration date for the consent, if different than one year. The consent will expire in one year unless you identify a different date.
- Understanding: Be sure the client understands what permission is being granted and how and why information will be shared. If needed, use a translated form and interpreter or read the form aloud. If the client needs more information, provide an additional copy of the DSHS Notice of Privacy Practices or refer the client to the public disclosure officer for your unit.

SIGNATURES:
- Client: Have client or a child over age of consent (13 for mental health and drug and alcohol services; 14 for HIV/AIDS and other STDs; any age for birth control and abortions; 18 for health care and other records) sign this box and insert the date of signature. The client may substitute a mark in this box that you witness. 
- Witness or Notary: A witness or notary may be needed to verify the client's identity if the client does not submit this form in person or if a program requests verification. This person should sign and print his or her name.
- Parent or Other Representative: If the client is a child under the age of consent, a parent or guardian must sign. If the child does not meet the age of consent for all records to be shared, both the child and the parent must sign. If the client has been declared legally incompetent, the court appointed guardian must sign and provide a copy of the order of appointment. If someone is signing in another capacity (including a person with a power of attorney or an estate representative), mark "other" and obtain a copy of the legal authority to act. The person signing must date the signature and give a telephone number or contact information.
Last Page!  Required Agreements: (LIHEAP)
LIHEAP, which stands for Low Income Home Energy Assistance Program, is a federal program that helps low income households pay for heating or cooling their homes.  In most states, it also helps people make sure their homes are more energy efficient by paying for certain home improvements, known as weatherization.
 
Most states will use LIHEAP to help you pay for your energy bill for heating or cooling your home and offer additional help in cases of energy crisis. A number of States may also offer weatherization services.

I certify that I have provided and reviewed all information on each page of this document and it is accurate to the best of my knowledge. I understand that I may be subject to criminal prosecution if I have knowingly provided false information. I further understand that I may request a Fair Hearing if the provision of the above information is not acted on to determine my eligibility within a reasonable time or if I do not receive benefits for which I feel I am eligible. I give my permission for this agency and Washington State Department of Commerce (COMMERCE) to request/release necessary information that may result in my receiving benefits from this assistance request and from similar and related programs administered by the State of Washington, including food assistance. I also give the above listed heating vendor(s) permission to establish a line of credit, and/or to release my account information to this agency or COMMERCE for current and future data analysis and eligibility determination. If the vendor is Seattle City Light, the permission to release customer billing and consumption information is allowed for up to six months from the date of this application. I understand that provision of my social security number is necessary to avoid duplicate energy assistance benefit payments to the same applicant household.  I hereby authorize energy program staff to also use my social security number for income verification purposes (including Employment Security Unemployment Insurance and DSHS Food Assistance). I further authorize this agency and COMMERCE to use my personal information within their organizations for the purpose of identifying and reporting unduplicated non-personal applicant data.

Required Agreement: PSE HELP

I certify that the income information I have provided to demonstrate my eligibility for the Bill Discount Rate and PSE HELP program is accurate. I realize that upon request I may be

asked for supporting documentation for verification. Also, eligibility for the Bill Discount Rate and PSE HELP programs must be re-declared each year, so I will need to reapply annually

to maintain any assistance I receive.

I hereby authorize Puget Sound Energy, Inc. (PSE) to disclose and exchange information about my application to my local Community Action Agency (Agency) and the Washington

State Department of Commerce (Commerce). I understand that this information is or may be confidential and will be protected from unauthorized disclosure. I may revoke this

authorization at any time by written notice to PSE and/or my local Agency.



Required Agreement: Energy and Money Saving Tips
Below are a few ideas to help you save money and use less energy.  To qualify for LIHEAP, you must acknowledge that you have read these tips.
  • Unplug electronic devices when not in use or when leaving home
  • Consider investing in a power strip to easily turn off multiple devices 
  • Turn off lights in rooms that aren’t being used
  • Reduce your refrigerator’s temperature (36 to 38 degrees) 
  • Make sure appliances are turned off after each use
  • Consider replacing bulbs with energy efficient lighting (CFL and LED lightbulbs)
  • Seal drafts in windows and doors with weather stripping, caulking, or plastic film 
  • Avoid using space heaters as much as possible, as they are expensive, unsafe, and not the most energy efficient when it comes to heating your entire home
  • Vacuum vents and heating baseboards regularly 
  • Add light colored curtains to windows and keep shades open during the day for sunlight and closed at night to keep warm air in
  • Consider installing a water saving shower head 
  • Lower water heaters thermostat to 120 degrees
  • Dust light fixtures regularly 
  • Take showers, not baths 
  • Run the dishwasher with full loads only and let dishes air dry 
  • Lower the thermostat every time you leave the house
  • Wash full loads of laundry with cold water, air dry clothes, and clean lint trap
  • Raise the heat temperature in your home gradually, since sudden increases will substantially increase your energy usage

REVIEW & SUBMIT YOUR APPLICATION

Upon hitting "Submit" at the bottom of this page, you MUST sign your response and provide an email.  You will receive a confirmation email with a link to verify your response's E-signature. Please check your junk folder if you do not see it in your email's Inbox.

But wait, Is anything missing?
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If you have uploaded all required documents, leave this blank!!!
Optional Survey


Thank you for taking the time to fill out Byrd Barr Place's Energy Assistance Application.  Please click Submit to complete your application.

Contact Information