APPLICATION FOR FINANCIAL HELP FOR WATER ASSISTANCE
LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP)
Agency Use Only
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How to apply for LIHWAP
1. Fill out the application below. For each section, read the instructions carefully, answer every question, and gather the required documents (extra papers) you need to turn in with your application. If your application is not complete, it could be delayed or turned down.
2. Send your completed application and extra papers to the LIHWAP agency that processes applications in the county you live in. See “Where to Send Your LIHWAP Application”. This is found on the last page of this application.
When to apply for LIHWAP
  • Send your application on or after Oct. 1st if: Any member of your household is age 60 or over, or if any household member is disabled. You may need to send extra papers with your application to show that your household has someone age 60 or over, or who is disabled.
  • Send your application on or after Nov. 1st if: Your household doesn’t include a person age 60 or over, or who is disabled.
After you send your application
The LIHWAP agency will review your application and extra papers you provided:
  • Your application will be reviewed within 30 working days after we receive it.
  • We’ll send you a letter by mail that tells if you qualify for LIHWAP and the amount you’ll get.
Important:
  • Even after you apply for LIHWAP, continue to pay your water and/or wastewater (sewer) bill so you don’t get disconnected.
  • When you pay your water and/or wastewater (sewer) bill, send it to the utility company that sent you the bill, not to the LIHWAP agency. LIHWAP agencies will only process your application. They will never accept utility payments, fees, or co-payments.
Part 1 - Contact Information/Address Corrections
Complete the below section. Please list a phone number if you have one so the contracted agency can contact you if we have questions on your application.
Name *
Home Address (Or address you are moving to) *
City
State
Zip Code
Unit Type
Unit Number
Mailing Address (If different from home address)
City
State
Zip Code
Unit Type
Unit Number
County of Residence *
Email Highly Recommended
Phone Number
Cell Number
In addition to mail, I would like to receive communication by Email and/or Text.
Part 2 - Household Members
List every person living in your household, starting with yourself. Fill in each box for every household member. If there are more than 10 people living in your home, list the others on a separate sheet of paper. Must include all nine numbers of the social security number and the month, day, and year of the birth date(s) for all household members.
Name SNAP?
Yes/No
Social Security Number Sex
M/F
Birth Date * Disabled?
Yes/No
Relationship to You Race U.S. Citizen?
Yes/No
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Have you or an immediate family member ever served in the U.S. Armed Forces?
If yes, would you like information about military-related services in Missouri?
Please visit www.veteranbenefits.mo.gov or call 573-522-4061 for information regarding military-related services in Missouri.
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Part 3 - Utility/Household Information
  • All applicants: Fill in this section and send a copy of your most recent water/wastewater (sewer) statement.
  • Applicants whose water has been disconnected or may be disconnected soon:
    • Send a copy of your disconnection notice along with the water/ wastewater (sewer) statement, and
    • If you or someone in your household suffers from a life threatening medical condition, send a medical statement from a qualified doctor or nurse. The statement should say that the person has a life-threatening medical condition, but does not have to state a diagnosis or condition.
Do you own your home or are you buying your home?
Do you or a household member suffer from a life-threatening medical condition?
Please enter your water and wastewater (sewer) bill information below.
  • Your household may apply for benefits up to the amount requested on this application, which must be equal or less than $750.
  • If you have a bill that includes other utilities, only include the amounts for water and wastewater (sewer).If you have a bill that has both water and wastewater (sewer) on the bill, the amounts must be separated below. If you have a bill from different companies for water and wastewater, you must apply for both at the same time and separate them below.
  • If you do not enter a requested amount or if the amount exceeds $750, the payment will be applied to the balance on the water bill first and then to wastewater (sewer).
  • If you are approved, your household can only receive up to $750 from October 1st through September 30th.
  • You must submit your current bill. (current = within 30 days prior to date you mail your application)
Water
Are you currently without water, because it got disconnected? *
Are you currently in threat of not having water, because it may be disconnected soon? *
Do you pay your water bill directly to your Landlord or as part of your rent? *
Amount Requested must be equal to or less than the bill submitted *
If you answered yes to either question, please fill in the disconnection date: *
List your water supplier’s name *
City *
Other Supplier Name
Whose name appears on the account? *
Account Number *
Wastewater (sewer)
Are you currently without wastewater (sewer), because it got disconnected? *
Are you currently in threat of not having wastewater (sewer), because it may be disconnected soon? *
Do you pay your wastewater bill directly to your Landlord or as part of your rent? *
Amount Requested
If you answered yes to either question, please fill in the disconnection date: *
List your wastewater (sewer) supplier’s name
City
Other Supplier Name
Whose name appears on the account?
Account Number
Part 4 - For Renters
If your water and/or wastewater bill is included in your rent, or if you pay your water and/or wastewater separately from your rent, but directly to the Landlord (property owner), the “LIHWAP Landlord Documentation Request” form (included in the last pages of application) needs to be completed. If you are approved for LIHWAP, the payment will be made the supplier. The Landlord must reduce your rent or water/wastewater by the amount of this payment.
  • If your water and/or wastewater is included in your rent, you can receive the amount included in your rent for your current bill and previous bills you have not paid to the Landlord. The amount cannot exceed $750.
  • If you pay your water and/or wastewater separately to your Landlord, you can receive the amount you currently owe the Landlord for water and/or wastewater up to $750.
The “LIHWAP Landlord Documentation Request” form must be signed by you and your Landlord. The landlord must agree to reduce current or past water and/or wastewater bills by the LIHWAP amount paid.
Are you in section 8 (subsidized housing) and required to pay a separate water and/or wastewater bill?
Do you share a water meter with your Landlord?
Landlord Name *
Landlord Email Highly Recommended
Landlord Phone *
Landlord Address *
City
State
Zip Code
Unit Type
Unit Number
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Part 5 - Income You Earn or Pay For Child Support
If anyone in your household has income from a job or self-employment:
  • Fill in this section to show all income anyone gets from tips, payments for service, and wages for all jobs, even if someone has more than one job, and
  • Send copies of papers that show all gross income received by anyone last month, such as paystubs. Gross income is income received before taxes are withheld. If anyone was employed in the last six (6) months, but did not receive income from that job last month, we may need proof of final wages earned and last date worked from that employer.
List everyone in your home age 18 or older who received income from a job last month. (Include all jobs.)
Name
Employer
How Often Paid?
Gross Pay
Still Employed?
Did anyone in the household receive income from self-employment last month?
If yes, send a copy of the most recent Federal Income Tax Form 1040, including Schedule 1, for each self-employed person along with your application.
Court-ordered Child Support that is paid to someone outside your household can be deducted so that it doesn’t count as income. To receive this deduction, fill in your 8-digit Child Support case number below
Did anyone pay court-ordered Child Support last month to someone outside of your household?
If yes, how much? *
Name of person who pays the Child Support *
List the 8-digit Child Support Case Number *
Part 6 - Income That Isn’t Earned
If anyone in your household receives income that does not come from a job or self-employment:
  • Fill in this section, and
  • Send copies of papers that show all unearned income anyone received last month.
Source of Income Who Receives This Income? Amount Received How Often Received?
Social Security
Supplemental Security Income (SSI)
Temporary Assistance for Needy Families (TANF)
Supplemental Aid to the Blind (SAB)
Blind Pension
Supplemental State Payments (SSP)
Foster Care
Alimony
Child Support
List 8-Digit Case Number:
Unemployment Compensation
Veterans Benefits
Pensions
Railroad Retirement
Rent Received from Land or Buildings
Money Received from Friends, Family,or Organizations
Armed Forces Allotment
Union Funds or Strike Benefits
Worker's Compensation or Temporary Private & Disability
Other Unearned Income
Specify:
Please use this section for household members that have the same income source.
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Part 7 - Savings and Other Accounts
If anyone in your household has savings or other accounts, fill in the total amounts of money everyone has in each type of account.
Type How Much? Type How Much?
Checking: Single and/or Joint Accounts Stocks/Bonds and Mutual Funds
Savings: Single and/or Joint Accounts IRA/KEOGH and/or Deferred Compensation Plans
CDs, Annuities, and/or Money Markets
Part 8 - Notice That You Can Get a Fair Hearing
As an applicant for the LIHWAP, you may request a hearing for the following reasons:
    1) If your LIHWAP application is denied.
    2) If your LIHWAP application is not reviewed timely.
A request for a hearing can be made in writing, by phone, by fax, or in-person. Hearing requests should be sent to the contracted agency in your county.
Papers you must send with your application to avoid processing delays (send copies as originals will not be returned)
Application that is completely filled in, signed, and dated.
Proof of Social Security Number for everyone in the household. (Such as social security card, award letter, W-2)
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Qualified Alien: Provide Proof of U.S. Citizenship and Immigration Services Form I-5551Permanent Resident Card, Re-entry Permit (a passport booklet for lawful permanent residents), USCIS Form I-94, or a I-94A.
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Copies of utility bills for your water and/or wastewater (sewer). The person listed on the water/ wastewater (sewer) bill must be a member of the household who is age 18 or older.
Household
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Papers you need to send if any member of your household got any income last month:
Proof of all income (both earned and unearned) from last month for all household members who got it. Household members who are active SNAP recipients do not need to provide proof of these incomes.
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Copies of the most recent Federal Income Tax Form 1040, including Schedule 1, for any household members who earned money from self-employment last month.
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Part 9 - Your Consent for the LIHWAP Agency to Process (Review) This Application
Read the Consent for Processing in the box below and sign. If you do not sign and date the application, your LIHWAP application will not be processed.
I hereby apply for assistance under the LIHWAP laws of the State of Missouri administered by the Department of Social Services (DSS). I declare that the information I have given is true, correct, and complete to the best of my knowledge. I realize that the information which I have given on this application will need to be verified by the LIHWAP agency.
If any household member declared on my application is currently receiving SNAP, TANF, or Child Support, I hereby authorize the LIHWAP agency to use my Family Support Division (FSD) file to see if I qualify for LIHWAP. I hereby authorize the LIHWAP agency, FSD, and my water/wastewater supplier share my customer, application and account information (such as: service address, water/wastewater source, customer account number, past due amount, notice of disconnection, etc.) to determine my eligibility and to otherwise administer the program. I give permission to DSS to use information provided on this form for purposes of research, evaluation, and analysis of the program. When applicable;I hereby authorize the LIHWAP agency, FSD to share my customer account, application, and eligibility information with my Landlords (property owners) to determine my eligibility and to otherwise administer the program.
I understand that I may be fined, imprisoned, or both under state or federal law if I make false statements on this application in order to get benefits I am not entitled to receive.
If your application is denied due to a non-participating water/wastewater supplier, would you like to be referred to another program for assistance?
Signature *
Date *
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WHERE TO SEND YOUR LIHWAP APPLICATION Search for your local office by referring to the county in which you live.
Audrain, Boone, Callaway, Cole, Cooper, Howard, Moniteau, Osage Central Missouri Community Action (CMCA)
800 N Providence Rd Ste 200
Columbia, MO 65203-4300
Phone number: (573) 443-1100 Fax (573) 370-1212
St. Louis County Community Action Agency of St. Louis County (CAASTLC)
2709 Woodson Rd
Overland, MO 63114-4817
Phone number: (314) 446-4427 Fax (314) 446-4480
Andrew, Buchanan, Clinton, DeKalb Community Action Partnership of Greater St. Joseph (CAPSTJOE)
1322 N. 36th St.
St. Joseph, MO 64506
Phone number: (816) 233-8281 Fax (816) 233-8262
Atchison, Gentry, Holt, Nodaway, Worth Community Services, Inc. of Northwest Missouri (CSI)
PO Box 328
Maryville, MO 64468-0328
Phone number: (660) 582-3113 Fax (660) 582-2965
Barton, Jasper, Newton, McDonald Economic Security Corporation of Southwest Area (ESC)
PO Box 207
Joplin, MO 64802-0207
Phone number: (417) 781-0352 Fax (417) 781-2011
Bollinger, Cape Girardeau, Iron, Madison, Perry, St. Francois, St. Genevieve, Washington East Missouri Action Agency (EMAA)
PO Box 308
Park Hills, MO 63601-0308
Phone number: (800) 392-8663 Fax (573) 431-7377
Dunklin, Mississippi, New Madrid, Pemiscot, Scott, Stoddard Delta Area Economic Opportunity Corporation (DAEOC)
99 Skyview Rd
Portageville, MO 63873-9180
Phone number: (573) 379-3851 Fax (573) 379-9139
Caldwell, Daviess, Grundy, Harrison, Linn, Livingston, Mercer, Putnam, Sullivan Community Action Partnership North Central Missouri (CAPNCM)
1506 Oklahoma Ave
Trenton, MO 64683-2587
Phone number: (660) 359-3907 Fax (660) 359-6619
City of St. Louis, Wellston Urban League (ULSTL)
1408 N. Kingshighway Blvd.
St. Louis, MO 63113
Phone number: (314) 615-3632 Fax (314) 615-3632
Jefferson, Franklin Jefferson-Franklin Community Action Corporation (JFCAC)
PO Box 920
Hillsboro, MO 63050-0920
Phone number: (636) 789-2686 Fax (636) 789-2866
Camden, Crawford, Gasconade, Laclede, Maries, Miller, Phelps, Pulaski Missouri Ozarks Community Action, Inc. (MOCA)
PO Box 69
Richland, MO 65556-0069
Phone number: (573) 765-3263 Fax (573) 765-0026
Carroll, Chariton, Johnson, Lafayette, Pettis, Ray, Saline Missouri Valley Community Action Agency (MVCAA)
1415 S Odell Ave
Marshall, MO 65340-3144
Phone number: (660) 831-5331 Fax (660) 831-5039
Lewis, Lincoln, Macon, Marion, Monroe, Montgomery, Pike, Ralls, Randolph, Shelby, St. Charles, Warren North East Community Action Corporation (NECAC)
805 Business Highway 61 N
Bowling Green, MO 63334-1351
Phone number: (573) 324-0120 Fax (573) 213-4858
Adair, Clark, Knox, Schuyler, Scotland Community Action Partnership North East Missouri (CAPNEMO)
PO Box 966
Kirksville, MO 63501-0966
Phone number: (660) 665-9855 Fax (660) 665-6557
Douglas, Howell, Oregon, Ozark, Texas, Wright Ozark Action, Inc. (OAI)
710 E Main St
West Plains, MO 65775-3307
Phone number: (417) 256-6147 Fax (417) 256-0333
Barry, Christian, Dade, Dallas, Greene, Lawrence, Polk, Stone, Taney, Webster Ozarks Area Community Action Corporation (OACAC)
215 S Barnes Ave
Springfield, MO 65802-2204
Phone number: (417) 864-3460 Fax (417) 864-3472
Butler, Carter, Dent, Reynolds, Ripley, Shannon, Wayne South Central Missouri Community Action Agency (SCMCAA)
PO Box 6
Winona, MO 65588-0006
Phone number: (800) 325-4633 Fax (573) 325-4543
Jackson, Clay, Platte Mid America Assistance Coalition (MAAC)
PO Box 32270
Kansas City, MO 64171
Phone number: (816) 831-1830 Fax (816) 831-1839
Bates, Benton, Cass, Cedar, Henry, Hickory, Morgan, St. Clair, Vernon West Central Missouri Community Action Agency (WCMCAA)
106 W 4th Street
Appleton City, MO 64724-1402
Phone number (660) 476-2185 Fax (660) 476-5901
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