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Resolution #5345 - agreement with fulton county health department
RESOLUTION NO. 5345 A RESOLUTION APPROVING AN AGREEMENT BETWEEN THE FULTON COUNTY HEALTH DEPARTMENT AND THE CITY OF CANTON WHEREAS, the City of Canton, Fulton County, Illinois (_the "City"), is a non-home rule unit of government; WHEREAS, the City, the Legal & Ordinance Committee of the City, the Mayor and the City Council have determined that it is necessary and in the best interests of the City of Canton for the City to enter into an agreement with the Fulton County Health Department relating to assisting low-income households for drinking water and wastewater services. NOW,THEREFORE,BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF CANTON,ILLINOIS, AS FOLLOWS: 1. That the Recital set forth above, and all facts and statements contained therein, are found to be true and correct and are hereby incorporated and adopted as part of this Resolution; 2. That the Agreement attached hereto as "Exhibit A" is hereby accepted, subject to any .farther revisions deemed necessary by the Mayor; 3. That the Mayor is hereby authorized to execute said Agreement, and any other related and necessary documents, on behalf of the City of Canton. 4. That this Resolution shall be in full force and effect immediately upon its passage by the City Council of the City of Canton, Illinois and approval by the Mayor thereof. PASSED by the City Council of the City of Canton, Illinois at a special meeting this 30th day of November, 2021 upon a roll call vote as follows: AYES: Alderperson Andra Chamberlin, Craig West,Jeff Fritz,Angela Lingenfelter, Greg Gossett NAYS: None ABSENT: Alderperson Justin Nelson, John Lovell, Angela Hale APP DOVED: "tM el , M or ATTES Diana Pavley-Rock, City Clerk VENDOR AGREEMENT This agreement, dated as of 09/01/2021 J is entered into by and between Fulton County Health Department (Agency), and Canton City Hall ' , a supplier of home water and/or waste water, (Vendor). PURPOSE Public Law No: 116-260 signed on December 27, 2020, included funding with instructions for the Administration for Children and Families(ACF)within the U.S. Department of Health and Human Services(HHS)to carry out grants to assist low-income households, particularly those with the lowest incomes,that pay a high proportion of household income for drinking water and wastewater services, by providing funds to owners or operators of public water systems or treatment works to reduce arrearages of and rates charged to such households for such services.This act requires that certain assurances be satisfied before assistance payments are made, on behalf of eligible individuals, to suppliers of drinking water and wastewater.This agreement defines the conditions that the Vendor must agree to so that the Agency can make assistance payments to the Vendor on behalf of eligible ho seholds. AGENCY RESPONSIBILITIES The Agency shall: • Accept and review client applications and determine eligibility of households for payments. • Submit applications subject to available funding to the Department for eligible households according to LIHWAP guidelines. • Follow procedures that minimize the time elapsing between the receipt of funds and their disbursement to vendor. • Make payments in a timely manner to the vendor on behalf of eligible households for the term of this agreement. • Follow sound fiscal management policies, including, but not limited to segregation of funds from other operating funds of the agency. • Notify customer and/or vendor of the customer's eligibility and total benefit amount. • Incorporate policies that assure the confidentiality of eligible household's usage, balance,and payments. VENDOR RESPONSIBILITIES The Vendor shall: • Provide an invoice that clearly states the cost of the water and/or wastewater service and fees only. • Accept benefit checks and vouchers on behalf of eligible households for the purpose of providing LIHWAP services for customers identified to receive such benefits. • Immediately apply the benefit payment to customer's current/past due bill, deposit/reconnect requirements, late fees, or arrearages to eliminate the amount owed by the customer for a period determined by the amount of the benefit. • Notify the customer of the amount of benefit payment applied to the customer's billing. • Refund any payments made in error to the LIHWAP agency who made the payment on behalf of the customer. • Keep customer records confidential. • Maintain records for four(4)years from the date of this agreement,or longer if the vendor is notified that a fiscal audit for a specific program year is unresolved. • Make records available for review by authorized staff of the Department of Commerce and Economic Opportunity, Office of Community Assistance. REQUIRED RECORDS FOR AUDIT PURPOSES • The vendor will keep records showing the following: • Name and address of households who received assistance payments. • Amount of assistance to each household. • Source of payment. OTHER PROVISIONS Term of Agreement This agreement is effective from the date of execution. Termination This agreement may be terminated by either party with a thirty(30)day written notice to the other party.Termination shall not extinguish authorized obligations incurred during the term of the agreement. If funding is withdrawn, reduced, or eliminated by Commerce,the agency has the right to terminate this agreement immediately. Assignment of Agreement Neither party may assign the agreement or any of the rights, benefits and remedies conferred upon it by this agreement to a third party without the prior written consent of the other party, which consent shall not be unreasonably withheld. The vendor and the agency do hereby agree to the conditions set forth in this agreement. Agency Signature. 44)-Yw Date Printed Name Katie Lynn Name of company Fulton County Health Department Vendor 4A Signature 6Date �� ��I/Z10Z I Printed Name N� , ') b cG,l-� Name of Company Ctr Ca0,-In 0 The date of this agreement is September 1,2021 through September 30,2023 Low Income Household Water Assistance Program (LIHWAP) AA ACF Office of Community Services Low-Income Household j Water Assistance Program (LIHWAP) Illinois Department of Commerce and Economic Opportunity 2022 Policy and Procedures Manual November 1, 2021 TABLE OF CONTENTS LIHWAP PROGRAM OVERVIEW...........................................................................1 LegislativeBackground.......................................................................................................... 1 ProgramDesign............................................:........................................................................ 2 SECTION 1 PROGRAM NEEDS, GOALS AND ALLOCATIONS Community Needs and Program Goals 1.1 Description of Priorities and Emergency Flexibilities.........................................................2 i 1.2 Operational Priorities and Emergency Flexibilities............................................................2 1.3 Implementation Date and Priority Groups........................................................................3 Estimated Funding Allocations 1.4 LIWHAP Funds Allocated.................................................................................................. 3 Categorically Eligible 1.5 Current Recipients categorically eligible for LIHWAP Assistance........................................3 Determination of Eligibility for Direct Enrollment 1.6 Countable Income............................................................................................................4 1.7 Forms of Countable Income .............................................................................................4 SECTION 2— BENEFITS Eligibility 2.1 Eligibility Threshold.......................................................................................................... 6 2.2 Renters and Water Assistance..........................................................................................6 2.3 Variables Used to Determine Benefits.............................................................................. 6 2.4 Benefit Levels.................................................................................................................. 6 2.5 Reconnection Assistance.................................................................................................. 6 2.6 Reconnection Assistance for New Residents.....................................................................7 2.7 Benefit Period.................................................................................................................. 7 2.8 Priority Period .................................................................................................................7 2.9 Prioritizing Water Assistance for the Vulnerable Population.............................................7 2.10 Ability to Include Disabled Means to Submit Applications for Benefits............................7 2.11 Home Visits.................................................................................................................... 7 2.12 Moratoriums on Shut Offs.............................................................................................. 7 SECTION 3-OUTREACH 3.1 Methods Used to Make Customers Aware of LIHWAP Assistance ..................................... 8 SECTION 4-COORDINATION 4.1 Coordination with Other Programs Available to Low-Income Households.........................8 4.2 Coordination with Relevant Regulatory Authorities the Govern Water Suppliers..............8 SECTION 5-AGENCY DESIGN 5.1 LAA To Determine Eligibility.............................................................................................9 5.2 Types of Local Administering Agencies (LAAs) ..................................................................9 SECTION 6- PROGRAM, FISCAL MONITORING AND AUDIT 6.1 GATA Procedures.............................................................................................................9 6.2 Monitoring Schedule and Protocol...................................................................................9 6.3 Selection for Review........................................................................................................ 9 6.4 HHS NOGA Exhibits........................................................................................................ 10 SECTION 7- FAIR HEARINGS 7.1 Fair, Independent, Hearing Procedures .......................................................................... 11 7.2 When and How Applicants are Informed of their Rights to Appeal.................................. 11 SECTION 8- PROGRAM INTEGRITY 8.1 Fraud Mechanisms......................................................................................................... 11 8.2 Identification Documentation Requirements.................................................................. 11 8.3 Identification Verification .............................................................................................. 11 8.4 Citizenship/Legal Residency Verification ........................................................................ 11 8.5 Income Verification........................................................................................................ 12 8.6 Protection of Privacy and Confidentiality....................................................................... 12 8.7 Verifying Authenticity.................................................................................................... 12 8.8 Benefits Policy 0 Water and Wastewater Utilities........................................................... 13 8.9 Investigations and Prosecutions..................................................................................... 13 SECTION 9-VENDORS 9.1 The Vendor Agreement.................................................................................................. 13 9.2 Securing the Agreement................................................................................................. 14 9.3 Types of agreements...................................................................................................... 14 9.4 Contents of the Vendor File ........................................................................................... 14 LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM (LIHWAP) OVERVIEW Purpose Low Income Household Water Assistance Program (LIHWAP) provides funds to assist low- income households with water and wastewater bills. LIHWAP grants are available to States,the District of Columbia, the Commonwealth of Puerto Rico, U.S.Territories, and Federally and state-recognized Indian Tribes and tribal organizations that received fiscal year 2021 Low Income Home Energy Assistance Program (LIHEAP)grants. The U.S. Department of Health and Human Services (HHS) through the Administration for Children and Families (ACF) launched the new Low-Income Household Water Assistance Program (LIHWAP) established under the Consolidated Appropriations Act of 2021. LIHWAP is a temporary emergency program that will help low-income households and families afford water and wastewater services during the Coronavirus pandemic. Along with funding provided under the American Rescue Plan Act of 2021, LIWHAP will help residents pay their water bills, avoid shutoffs and support household water system reconnections related to non-payment. LIHWAP provides grants to states,territories and tribes to work with private owners and operators of public water systems and treatment. Although Congress established LIHWAP as an emergency program to help states respond to the coronavirus pandemic, ACF is directing states to model LIHWAP after the existing Low-Income Home Energy Assistance Program (LIHEAP), meaning county governments functioning as local LIHEAP agencies might also be responsible for administering this new program. In 13 states, county governments either fully administer the LIHEAP program or share that responsibility with local community-based agencies. Legislative Background Water Assistance Program Funding Plan Available Through American Rescue Plan Act • The is no permanent authorization for LIHWAP • Congress appropriated funding in the Consolidated Appropriations Act of 2021 and an additional funding through the American Rescue Plan Act (ARP) of 2021 for new emergency water and wastewater assistance program. • The legislation provided emergency assistance to low-income households, particularly those with the lowest incomes,that pay a high proportion of household income for drinking water and wastewater services. • Grantees must provide funds to owners or operators of public water systems or treatment facilities to reduce arrearages of and rates charged to such households for such services. • Use existing processes, procedures, policies, and systems in place to provide assistance to low-income households, including by using existing programs and program announcements, application and approval processes. Page 1 1. The administration of this program is authorized under Section 533 Title V of Division H of the Consolidated Appropriations Act, 2021, Public Law No: 116-260. Consistent with legislative instructions, program requirements use existing processes, procedures, and policies currently in place to provide assistance to low-income households. In particular, OCS has closely modeled the Low-Income Household Water Assistance Program's (LIHWAP)terms and conditions on assurances and requirements outlined in the Low- Income Household Energy Assistance Act, 42 U.S.C. 8621 et seq. 2. The Uniform Administrative Requirements, Cost Principles, and Audit Requirements for HHS Awards is located under 45 CFR Part 75. In accordance with 45 CFR 75.101 applicability, this program must comply with 45 CFR Part 75 in its entirety. No exceptions have been identified. 3. Additional applicable regulations and requirements can be found in the General Terms and Conditions for Mandatory: Formula, Block and Entitlement Grants. 4. In Illinois, LIHWAP applicants are served by a pre-approved group of Local Administering Agencies.A Local Administering Agency(LAA) is a Community Action Agency(CAA) or other community-bases organization or unit of general purpose local government or public agency which is authorized to administer LIHWAP funds received from the Department of Commerce and Economic Opportunity (the Department) SECTION 1- PROGRAM NEEDS, GOALS AND ALLOCATIONS Community Needs and Program Goals 1.1 Description of Emergency Household Drinking Water and Wastewater Needs The Office of Community Assistance (OCA) priorities are the restoration of household water services, including drinking water and wastewater services by reducing arrearages, and reducing rates charged to households. Fees allowed include late fees, reconnection fees or any regular fees that are included on the bill. 1.2 Operational Priorities and Emergency Flexibilities Consistent with the goal of the American Rescue Plan to provide immediate relief to the American people,the Program's priority is to immediately restore services to households without current water services, immediate payment of existing arrearages (defined as owing$250 or more for water and wastewater combined)and to prevent disconnection of drinking water and wastewater services after a previous moratorium on water services due to Covid-19. For the City of Chicago,the city's moratorium will continue indefinitely, so the priority is to reduce arrearages only for Chicago residents. Page 2 1.3 Implementation Date and Priority Groups There will not be a statewide start date. A roll out of the program will occur as the grants are executed throughout November at each local agency. The proposed implementation of the water program will be November 1, 2021 and will remain through August 31, 2023, or until funds are exhausted. According to funding availability, Local Administering Agencies will offer three types of assistance: Priority Group 1: Disconnected services Priority Group 2: Imminent Disconnect Priority Group 3: Households with past due arrearages$250 or more Estimated Funding Allocations 1.4 LIHWAP Funds Allocated Estimated amounts of available LIHWAP funds will be used for each component operated. Consolidation Of American Rescue Plan Appropriations Act Of Grant Percentage 2021 Percentage (%) Household Benefits 77% 77% Outreach/Eligibility 8% 8% Determination Administration (State) 5% 5% Administration- 10% 10% Subrecipients Total 100% 100% Categorical Eligibility 1.5 Current Recipients are categorically eligible for LIHWAP Assistance Recipients are categorically eligible for LIHWAP without providing additional income verification for the following programs: • Low Income Home Energy Assistance Program (LIHEAP) • Means-tested Veterans Programs • Supplemental Security Income (SSI) • Supplemental Nutrition Assistance Program (SNAP) • Temporary Assistance for Needy Families(TANF) Page 3 Documentation will be necessary to prove the household is currently receiving any one of these types of assistance. Determination of Eligibility for Direct Enrollment 1.6 Countable Income Gross income (before taxes or any other deduction) must be used to verify income with limited exceptions.The main exception is Social Security checks that have a Medicare deduction ONLY for Hospital, Medical and/or Prescription. Drug insurance (Parts A, B, and D). 1.7 Forms of Countable Income Applicable Countable Income used to determine a household's eligibility for LIHWAP can be found below. The following are considered income and require 30-day documentation: • Alimony Annuities (a fixed sum of money paid to someone each year,typically for the rest of their life: divide by the appropriate number to get a monthly amount when applicable) • Armed Forces allotments&allowances for housing, food, and clothing (BAH on paystub) • Cash gifts, excluding Every Dollar Counts/Universal Basic Income projects approved by the Department(may be verified via Income Affidavit or benefits protection letter in the following counties: Cook, Iroquois, Kane, LaSalle, Lee, Livingston, Ogle, Will and Winnebago) • Child Support • Commission checks that cover more than one month should be divided by the appropriate number of months to equal the 30-day income requirement • Contract Income • Educational Stipends (a periodic payment, especially a scholarship or fellowship allowance granted to a student) • Farm Income-such as income from selling farm crops or livestock or similar bulk product once a year, must be divided by 12 months to equal the 30-day income requirement • Federal Black Lung Benefits • Gambling proceeds and/or annual gross income should not exceed the annual 200% income eligibility • "GoFundMe" Money received • GA(General Assistance) • Interest, dividends, or royalties • IRA- Regular payments of an IRA(Individual Retirement Account)should be considered income just like a pension • Legal settlements with regular payments (not lump sum) • Lottery-A one-time lump sum payment of lottery winnings must be divided by 12 months to equal the 30-day income requirement Page 4 • Onetime lump-sum payments such as rebates/credits, winnings from lotteries (see above "Lottery"), refund deposits, etc. • Online income received from selling items regularly on eBay, PayPal, Facebook or other sites for profit must be divided by 12 months to equal the 30-day income requirement • Payments for mortgage or sales contracts (i.e. income received for contract-for-deed sales) • Railroad Retirement Benefits • Rental income- counted if the applicant rents property outside his/her own household or the applicant shares his/her home, i.e., one household unit with a boarder, lodger and/or renter who is NOT related: DO NOT COUNT RENTERS/BOARDERS WITHIN THE HOME AS HOUSEHOLD MEMBERS OR INCLUDE THEIR INCOME IN THE HOUSEHOLDS INCOME • Rideshare,vehicle, and/or transport services for hire (Uber, Lyft, Relay Rides, Sidecar, etc.) - calculate the 30-day income using customer logs, ledgers, and/or printouts from PayPal, etc. NOTE: If the expenses are claimed, a Self-Employed worksheet with documentation of expenses are required. An Income Affidavit will be accepted if expense deductions are not submitted by the customer. • Self-Employment • Sick pay • Social Security income received for a spouse that resides in a nursing home/assisted living facility that is not paid directly and completely to the facility is countable income for the LIHEAP household • Strike benefits • Support of guardian and/or adopted child(ren) income received (adoption subsidies) • Tips and gratuities; money received over and above payment due for a service • Unemployment Insurance (state only) • Wages • Worker's Compensation (insurance payments made directly to the insured) The following sources are not applicable forms of countable income to determine eligibility: • Temporary Assistance for Needy Families (TANF) benefits (countable in LIHEAP) • Supplemental Nutrition Assistance Program (SNAP) • Women, Infants, and Children Supplemental Nutrition Program (WIC) benefits • Covid 19 Economic Impact Payments (Stimulus Checks) Page 5 SECTION 2— BENEFITS Eligibility 2.1 Eligibility threshold The eligibility threshold for LIHWAP will be 150%of the Federal Poverty Level or 60%of State Median Income.This is approximately 200%of the Federal Poverty Level. 2.2 Renters and Water Assistance Renters may qualify for LIHWAP benefits provided they can show proof that: • the water and/or wastewater utilities are included in their rent. • and the amount past due has led to disconnection status or imminent disconnection. To qualify,the applicant must submit a bill that shows that they are in disconnect status, in danger of being disconnected, or their arrearage amount is$250 or greater for their water and wastewater bills combined. The customer may use their lease or other proof, such as a statement from the landlord to verify the water and wastewater utilities are included in their rent.They may also use the LIHWAP Utilities Included in Rent Verification Form.This can be completed by the landlord and signed or may be verified at the Local Administering Agency by an Intake Worker. 2.3 Variables used to determine benefit levels • Income • Household Drinking Water Burden • Household Wastewater Burden • Other: Income determines the burden of a ratio of income cost of the water. Households will receive a benefit to reconnect and/or to reduce arrearage based on their drinking water and wastewater arrearage amounts, and their amount to reconnect, with late fees and reconnections fees associated. 2.4 Benefit Levels • Minimum Benefit Amount to Reconnect-$0 • Minimum Benefit Amount to Reduce Arrearages without Disconnection or threat of Disconnection -$250 • Maximum Benefit-$1500 2.5 Reconnection Assistance The goal is to restore services as soon as possible. While we are not mandating reconnection within 48 hours, we are strongly recommending it. For the customers who have service, but you are helping them with arrearages only, you can process within 30 days. Page 6 2.6 Reconnection Assistance for New Residents Reconnection Assistance also covers households that are trying to get into a new residence but cannot get utilities in their name because of high outstanding/old balances. These are considered "crisis" applications. In these cases, we would mirror LIHEAP and we would assist these customers to get services with a water deposit and help them with their arrearages. 2.7 Benefit Period The LIHWAP Benefit is a limited, one-time, assistance program designed to help households that are facing the threat of imminent disconnection, have already been disconnected or have past due (arrearage) balances over$250 for their water and wastewater services combined. Customers may apply one time for water and one time for wastewater for the life of the program, which is December 1, 2021—August 31, 2023. LIHWAP Pr©gram does not allow credits; however, if the payment was made after the pledge, ,he credit balance or refund i3s be'wwtween the customer and the vendor. A refund would not •ome back to the LAA because t wou l d've been thME st omer's y pamen t t hat crea ted the -red'it, not the LIHWAP pled a/paymen i . 2.8 Priority Period There is no priority period for LIHWAP, and the program will be available year-round.The only priority for LIHWAP will be for people with high water burdens, people facing imminent disconnection or those in disconnect status. A priority period would not help customers who have needs later in the year. 2.9 Prioritizing Water Assistance for the Vulnerable Population While the Office of Community Assistance will make every effort to assist the most vulnerable population, our funding allows us the ability to assist all customers who are disconnected, in threat of disconnection and those households with arrearages at least $250 for water,wastewater or the combination of both. 2.10Ability to Include the Disabled the Means to Submit Applications for Benefits Application may be done by in-person, by proxy,via telephone, email, U.S mail or other secure delivery service. 2.11 Home Visits Home visits are currently discouraged at this time due to COVID-19; however, the applicant may apply for LIHWAP without leaving their home by allowing someone to apply for them by proxy, fill out an application via telephone, or by contacting the agency for assistance in completing the application. Page 7 2.12 Moratoriums on Shut Offs - Currently the City of Chicago's moratorium is expected to continue indefinitely.There are no other locations in the state of Illinois that currently have a moratorium on shut offs. SECTION 3—OUTREACH 3.1 Methods Used to Make Customers Aware of LIHWAP Assistance The methods the local agencies throughout may use the following to make customers aware of LIHWAP Assistance: • Posters and flyers will be used in local and county social service offices, Social Security Office,VA Offices, etc. • Articles and/or public service announcements will be placed in local newspapers or broadcast media announcements. • Inserts in water vendor utility bills will be used to inform individuals of the availability of all types of LIHWAP assistance. • Multi-lingual announcements will be used in languages spoken by low-income households within utility service area and/or notification in ethnic language news and broadcast media outlets. • The Office of Community Assistance will Inform low-income applicants of the availability of all types of LIHWAP assistance at application intake for other low-income programs, such as LIHEAP and assessment in CSBG. • The State office will encourage Local Administering Agencies and Community Action Agencies to use all types of outreach listed above, including working with the water vendors to advertise the assistance available to their customers and the use of the agencies social media (Facebook)to inform households of the availability of LIHWAP. SECTION 4—COORDINATION 4.1 Coordination with Other Programs Available to Low-Income Households • The Local Administering Agencies (LAA's)will provide information at intake for LIHEAP, PIPP, IHWAP and CSBG. • The Office of Community Assistance is working with other State agency programs such as SNAP and TANF to increase participation in LIHEAP, LIHWAP, IHWAP and CSBG. 4.2 Coordination with Relevant Regulatory Authorities that Govern Water Suppliers The Illinois Commerce Commission oversees the provision of adequate, reliable, efficient, and safe services to Illinois citizens served by water and sewer public utility companies. Page 8 SECTION 5—AGENCY DESIGNATION 5.1 LAA to Determine Eligibility The Office of Community Assistance categorizes itself as a Commerce Agency and a Community Service Agency. The Local Administering Agency(LAA) will determine the client's eligibility and process the benefit payments to the water service providers. Eligibility for selecting Local Administering Agencies are determined when the agency submits a grant application and is approved. 5.2 Types of Local Administering Agencies(LAA's) The State uses various types of local administering agencies, including, but not limited to • Community Action Agencies • Local Governments • City Governments • County Governments • Other Non-Profit Agencies SECTION 6— PROGRAM, FISCAL MONITORING AND AUDIT 6.1 GATA Procedures The Office of Community Assistance requires following GATA (Grant Accounting and Transparency Act) procedures. Grantee strategies for monitoring compliance with the Grantee's and Federal LIHWAP policies and procedures for Grantee employees will be through departmental oversight. The Local Administering Agencies will be monitored periodically by: • On-site evaluation • Annual program review • Monitoring through central database • Desk Reviews • Client File Testing/sampling 6.2 Monitoring Schedule and Protocol Fiscal and programmatic monitoring will be accomplished by the end of the program year. Those agencies who have spent at least 50%of their allocation will be monitored.All others will be monitored subsequently. 6.3 Selection for Review Each agency will be monitored through desk review or on-site, as required by HHS. • Annual Site visits will be based on a combination of risk assessment scoring, spending amount and date of last visit. Page 9 • Desk Reviews will be conducted on an annual basis based on risk management and spending amount.Those not selected for on-site monitoring the first year will be selected for desk review. 6.4 02tJ2y2 HHS NOGA Exhibits Exhibit B. Deliverables or Milestones Grantee shall perform the following tasks, including but not limited to: 1. Grantee must inform customer of benefit amount at time of intake. Grantee shall attempt to obtain a vendor agreement with each water and/or wastewater supplier.A water bill pledge must be completed for each customer payment. 2. On a quarterly basis, following the same schedule as CSBG, Grantee will upload the LIHWAP STARS Activity Report and a copy of the GRS screen 352 to the assigned quarter report tool in STARS. Exhibit E. Performance Measures: Grantee's performance for this Award will be measured based on the LIHWAP requirements, as applicable,that Grantor will review periodically during the Award Term, including, but not limited to the following: 1. The number of applications that have exceeded the 30-day timeframe to reach approved or denied for LIHWAP benefit status. 2. The number of LAA/CAA unpaid LIHWAP benefits that are more than 60 days from the service date. SECTION 7— FAIR HEARINGS 7.1 Fair, Independent, Hearing Procedures The Department will follow a system developed for LIHEAP and IHWAP that provides an opportunity for a fair resolution process to households whose claims for assistance under LIHWAP are denied or are not acted upon with reasonable time.The resolution process includes three levels of review: 1.The Informal Conference conducted at the Local Administering Agency 2. The Review of the LAA decision at the State/Department's programmatic review level 3. The Formal Administrative Hearing through the Department's administrative hearing rules (56 III Admin Code 2605) The LAA shall designate a hearing officer to conduct the informal conference.The informal conference is designed to understand the action taken or the reason for delay. At the end of the informal conference, the LAA will give the claimant a written statement describing the result of the conference and citing the policy reasons for the decision. A copy of the report must be filed in the applicant's name. In the event the claimant is not satisfied with the informal conference determination, the claimant may request a review at the Department's Formal Administrative Hearing Process. Page 10 7.2 When and How Applicants are informed of the rights the appeal Applicants are informed at intake and receive a copy of their appeal rights. Posters are places in al intake sights as an additional form of notification of fair hearing rights. SECTION 8— PROGRAM INTEGRITY 8.1 Fraud Reporting Mechanisms • On-line fraud reporting • Report directly to the local administering agency/district office or Grantee Office • Report to Inspector General or Attorney General • Forms and procedures in place for local agencies/district offices and vendors to report fraud, waste, and abuse • Report directly to the State LIHWAP Office: o Department of Commerce and Economic Opportunity Office of Community Assistance:Attn: Fraud Unit 500 East Monroe Springfield, II 62701 8.2 Identification Documentation Requirements • Social Security Cards are requested at intake to be photocopied and retained for all household members. Cards are not necessary if there is proof of SSN on a previous LIHEAP app. This is for new LIHEAP customers only. • Social Security Number(without actual card) is required for all household members. • If an applicant does not have a Social Security Number(SSN)they must provide an Individual Taxpayer Identification Number(ITIN). [TIN (Individual Taxpayer Identification Number used,for tax processing by the Internal Revenue Service) • Metal Social Security cards are not acceptable;they are memorabilia and not government issue. • A photocopy of the applicant's Drivers' License or Illinois State Identification Card is requested but not required at intake for the Head of Household (person submitting application). 8.3 Identification Verification LIHWAP will use resources available to the State LIHEAP program, as needed, to verify identification documentation.The State office has an interagency agreement with the Illinois Department of Human Services (DHS)for investigative and eligibility verification. In addition,the State LIHEAP office has an interagency agreement with the Illinois Department of Employment Security to assist with income verification. 8.4 Citizenship/Legal Residency Verification All applicants must provide a valid Social Security Number(SSN) or Individual Taxpayer Identification Number/ITIN for all persons in the household in addition to income documentation. A valid SSN is.defined as a nine-digit number issued to U.S. citizens, Page 11 permanent residents, and qualified temporary residents by the Social Security Administration.An Individual Taxpayer Identification Number (ITIN) is a United States tax processing number issued by the Internal Revenue Service (IRS). To receive federally funded LIHWAP benefits, each applicant must have at least one household member who is a U.S. Citizen. Income of all household members—regardless of immigration status—must be documented, verified, and included in the calculation of the LIHWAP benefit amount.The income of any non-qualified alien must be placed in the "Other"field for the head of household on the combined LIHEAP/LIHWAP application. 8.5 Income Verification Note: Income verification applies only to households that have not been determined to be categorically eligible based on enrollment in other programs. (see Section 2.5) Methods used for Income Verification: • Bank statements • Pay Stubs • Social Security Award Letters • Unemployment Insurance Letters • Zero-Income Statements 8.6 Protection of Privacy and Confidentiality • There is policy in place prohibiting release of information without written consent. • Grantee LIHWAP database includes privacy/confidentiality safeguards. • Employee Training is provided for the Local Administering Agencies and the Grant management Staff. • Physical files must be stored in a secure location.The Agency may keep them separate, with LIHEAP or with CSBG files.The agency may decide how they want to keep their files; however, the LAA will need to be able to upload or produce the complete file for monitoring purposes. o LIHWAP files must contain the following: ■ Thoroughly completed LIHEAP/IWAP/LIHWAP Application. ■ Proof of 30-day income for all applicable household members or Zero Income Affidavits&Supporting Documents. ■ Proof of Social Security numbers for all household members. ■ Most recent utility bill (s) ■ Proof that the household is disconnected or in danger of imminent disconnection. ■ Water/Wastewater Pledge. ■ Rent verification (when necessary). 8.7 Verifying Authenticity • All vendors must supply a valid Federal Employer Identification Number(FEIN), SSN or Page 12 W-9 Form. • Vendors are verified through water and wastewater bills provided by the household. 8.8 Benefits Policy—Water and Wastewater Utilities • Applicants are required to submit proof of physical residency. • Applicants must submit a current water or wastewater bill. • Exchange with utilities that verify: o Account ownership o Balances o Payment history • Payments should be coordinated among other water and wastewater assistance programs to avoid duplication of payments. • Payments of water suppliers and invoices from water suppliers are reviewed for accuracy. • Procedures are in place to require prompt refunds from the utilities in cases of account closure. • Separation of duties between intake and payment approval. • Vendor agreements specify requirements selected above and provide enforcement mechanism. 8.9 Investigations and Prosecutions • Customers found to have committed fraud are banned from LIHWAP assistance for the remainder of the current program. • Contracts with local agencies require that employees found to have committed fraud are reprimanded or terminated. • The Grantee will attempt collection of improper payments. • The Local Agency or Grantee may conduct investigation of fraud complaints from the public. • Referrals are sent to the State Inspector General. • Vendors found to have committed fraud may no longer participate in LIHWAP. • Based on sufficient evidence of fraudulent activity,the Department may sanction LIHWAP customers, including staff, intake contractors,volunteers,and vendors. SECTION 9—VENDORS 9.1 Vendor Agreement A critical part of the Low-Income Household Water Assistance Program is securing vendor agreements. This agreement sets guidelines that the vendor must follow. The Vendor Agreement must: • Clearly define all the details and roles of each party Page 13 • Set expectations for both parties • Establish provisions for circumstantial changes • Detail consequences if services are not fulfilled • Fulfill federal requirement for consumer protection We do not want households to be left unserved due to an unwilling vendor. If a water vendor does not participate, they will not receive the funding to lower the debt owed to them by eligible households. All efforts will be made to negotiate with vendor to resolve any issues. 9.2 Securing the Agreement Secure two signed copies of every agreement—one for the agency file and one for the vendor file. Keep this agreement for monitoring purposes once an agreement has been signed: 1. Vendor name 2. Vendor address 3. Vendor telephone number and contact person 4. Vendor Federal Employer's Identification Number(FEIN) The FEIN is always a nine-digit number(no letters). If the vendor does not have a FEIN, use the owner's Social Security number, which is also a nine-digit number. 9.3 Types of Agreements There are two vendor agreements available for agencies to consider when securing a payment from the Water or Wastewater Utility. 1. The Standard Vendor Agreement—This is-the first and best agreement to use with the both the Publicly Owned Water Vendors (managed by local or state government) and the Privately/Shareholder Owner Water Vendors) for-profit systems managed by investors or shareholders) 2. Simplified agreements may be the only thing possible with small utilities/vendors that do not want to sign the Standard Vendor Agreement. Local Agencies may use the Water Bill Pledge for participation in the Low-Income Household Water Assistance Program in those cases, or a form that the local administering agency uses for smaller vendors; however,the agency should always try to use the Standard Vendor Agreement, if possible. 9.4 Contents of the Vendor File An important aspect of the Low-Income Water Assistance Program is the relationship between the agency (LAA) and various water and wastewater vendors in their area.The agency should secure a file on each Water or Wastewater Vendor.These agreements should include: • the vendor name, address, telephone number and the Federal Employers Identification Number(FEIN) Page 14 • All Department vendor bulletins and memorandums relating to the energy program • A copy of the Illinois Administrative Code 280 and 281, (Illinois Commerce Commission rules governing service) if applicable. • Miscellaneous correspondence, including correspondence to and from the vendors and contact persons, etc. Page 15 INDEX OF FORMS FOR LIHWAP MANUAL Affidavit for Legal Name Change LIHWAP Appeals Rights Application File Checklist for LIHWAP—Fillable Eligibility Verification Form LIHWAP Income Affidavit for LIHWAP—Fillable Intake Workers Verification of Income on IES and/or IDES- Fillable LIHWAP Customer Flier LIHWAP Documentation Request Form LIHWAP Water and Wastewater Utilities Included in Rent LIHWAP Water and Wastewater Utilities Included in the Rent—Fillable Notification Notice for Approval of LIHWAP Benefits Notification Notice for Denial of LIHWAP Benefits PY2022 Paper Application (combined LIHEAP, IWHAP, LIHWAP) Request for Formal Hearing Request for Informal Conference Request for State Review Self-Employment Worksheet—Mileage for 2021-22 Standard Vendor Agreement Standard Vendor Agreement—Fillable Universal Signature Page Universal Signature Page Proxy Verification of Assistance Paying Bills Water Pledge Water Pledge- Fillable Zero Income Affidavit LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM AFFIDAVIT OF LEGAL NAME(S) certify that I've been known by the name(s) listed below. I further certify that the names are legal and belong tome. Print Name (known by) Print Name (known by) I understand that to perjure myself in order to obtain assistance is a fraudulent offense for which I can be prosecuted. Signature Date REV 08/19 Application#: YU_ _ UR RIGHT%JO Under the Low-Income Home Energy Assistance Program, Low Income Household Water Assistance Program and the Illinois Home Weatherization Assistance Program The Low-Income Home Energy Assistance Program Appeal Process (LIHEAP) is designed to help income eligible households meet the rising cost of home energy. The first step in the appeal process is an informal Eligibility and the assistance level depend on: conference at a local agency. You may request an informal conference by contacting your: . the household's income and number of members; ■ whether or not the household pays for its home energy costs directly or the home energy costs are included in the rent, and if rent exceeds 30% of income; ■ the type of home energy fuel if the household pays During this hearing you have the right to: directly; and ■ be represented or bring to the conference a ■ the region in which the household is located. representative of your choice. ■ present oral and written statements and other Low-Income Household Water Assistance Program evidence. (LIHWAP) provides funds to assist low-income ■ cross-examine witnesses; and/or households with water and wastewater bills. ■ bring an interpreter, if needed. Eligibility and the assistance level depend on: ■ the household's income. The informal conference will be held by a designated hearing officer at the Local Administering Agency. ■ whether or not the household is in crisis by being The purpose of the informal conference is to ensure disconnected, imminent disconnection and being in that the applicant understands the outcome of the arrearage of$250 or more. application and/or the reason for a delay. The applicant must request a conference within 30 days of The Illinois Home Weatherization Assistance Program receipt of a notice of a decision on the applicant's (IHWAP) is designed to help income eligible households application or within 60 days if notification has not conserve fuel and save money by making their homes been received. and apartments energy efficient. Eligibility for the Weatherization Program depends on: If you have completed the informal conference and still are not satisfied with the decision, you may ■ the household's income and number of members; request a state review. The Local Administering and Agency will advise you on how to request a state ■ whether or not the household can show proof review, the second step in the process. of home ownership, or the landlord complies with The state office will review your case and advise both the program requirements. you and the local agency of the decision. If you are still unsatisfied after the state review, you Appeal Rights may request a formal hearing by a state appeals officer. This testimony will be recorded, and a written You have the right of appeal to any of the programs if: decisionwill be based on the record. ■ your application was not processed in a timely fashion (approximately 30 days after you submit These are Your Rights. If you do not understand all your information to the agency). them,please contact your Local Administering Agency. ■ you disagree with the outcome of your application. ■ or you believe the payment or benefit received is To report suspected Energy Assistance fraud or incorrect. abuse:DCEO Office of Community Assistance,Attn: Fraud Unit, 500 E. Monroe St., Springfield, IL 62701 � o Illinois o Department of Commerce & Economic Opportunity r ,qGc Ye*+ti 1 OFFICE OF COMMUNITY ASSISTANCE Applicant File Checklist for LIHWAP App ID Agency Name Program Year Intake Site County Household Members App Date HOH Name Age Birth Date 30 Day Income El DOCUMENTATION ❑ Thoroughly completed and signed Energy Assistance application. ❑ Proof of 30-day income for all applicable household members or Zero Income Affidavits & ❑ Supporting Docs. ❑ Proof of Social Security number for all household members ❑ Most recent utility bill (s) ❑ This household is disconnected ❑ Water/Wastewater Pledge ❑ This household was in danger of disconnection ❑ Rent verification (when necessary) ❑This household has more than$250 in arrears INTAKE WORKER ❑ I explained the notification of assistance and/or denial procedures. ❑ I advised the customer to continue to pay all utility bills. ❑ I explained that the LIHWAP Benefit is a limited, one-time,assistance program designed to help'households that are facing the threat of imminent disconnection, have already been disconnected or have past due(arrearage) balances over$250 for their water and wastewater services combined. ❑ I explained the payment procedures. ❑ I explained the hearing&appeal process,& provided a copy of the Customer's Rights form. *This is an optional form. If this form is used,at least one of these signatures is required. Intake Worker Signature* Date: Verifier Signature Date: LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM ELIGIBILITY VERIFICATION FORM APPLICANT NAME APPLICATION ID# (from Program Year2022) ELIGIBILITY DOES NOT NEED TO BE REDETERMINED: I have checked agency files and/or THE DEPARTMENT computer records. These records verify the above-named applicant household was determined Energy Assistance Program eligible within the 2022 Program Year. I have duplicated this record of income on the customer's current application Intake Worker Signature Date REV 03/21 Application#: Reset Form Income Affidavit for LIHWAP Application Name: County: Application Number: I/We, attest to the fact I/We have received $ gross income for the period covering _to I/We met my/our financial obligations during the 30-day period by: I understand that to perjure myself in order to obtain assistance is a fraudulent offense for which I can be prosecuted. Applicant Signature Date Intake Worker or Verifier's Signature: Date: LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM INTAKE WORKER'S DOCUMENTATION AFFIDAVIT TO VERIFY CONFIDENTIAL INFORMATION OBTAINED FROM THE DEPARTMENT OF HUMAN SERVICES ITEGRATED ELIGIBILITY SYSTEM (IES)AND/OR ILLINOIS DEPARTMENT OF EMPLOYMENT SERVICES(IDES) Intake Worker: Date: Local Administering Agency: I,the undersigned, attest that I have seen the following information via secured electronic data on behalf of the household seeking assistance for: Low Income Home Energy Assistance Program Low Income Household Water Assistance Program Income Verification for HH Member Name: Income Amount Type of Income From To Social Security Verification for HH Member Name: (do not display social security number on this form) Social Security Number on the Agency's Computer System Matches Number on Application Yes F� No 0— The Information was obtained via Agency Computer System from: IES IDES Additional Information (other) Please Explain: I understand that all client information collected or received by the Agency is CONFIDENTIAL. Every employee,agent, and contractor of the Agencies,and every other person or entity who receives the Agencies'client information,must protect the privacy and security of client information. Signature of Intake Worker Date Application Number LIHWAP DOCUMENTATION REQUEST A copy of this form must be in the customer file anytime documentation is requested. Applicant's Name Date Application ID# The following documentation is needed before your application can be processed: INCOME INFORMATION 1. ❑ Social Security Administration Income 2. ❑ Supplemental Security Income 3. ❑ Unemployment Benefits 4. ❑ Pension 5. ❑ Income Documentation from Wages 6. ❑ ero Income Affidavit 7. ❑ Income Documentation from (Note:Check stubs must include payee,source,time period and amount) 8. ❑ Savings and/or checking account OTHER NEEDED INFORMATION 9. ❑ Affidavit—Reason: 10. ❑ Social Security Number(s)for: 11. ❑ . Thoroughly Completed and signed LIHWAP Application 12. ❑ tilities Included in Rent Verification 13. ❑ Verification Water/Wastewater Bill Disconnected Status 14. ❑ Verification of Water Wastewater Bill Imminent Disconnection 15. ❑ Verification Household is in arrears of 2 and over 16. ❑ Other information—Specify: The above information must be received in the Agency office at: On or before , 20_ I understand that noncompliance with this request for information may result in the denial of assistance. I understand it.is my responsibility to obtain the required information. Applicant Signature Date Intake Worker Signature Date PLEASE RETURN THIS FORM WITH THE REQUESTED DOCUMENTATION REV 08/19 Application#: Low Income Household Water Assistance Program LIHWAP WATER AND WASTEWATER UTILITIES INCLUDED IN RENT VERIFICATION Applicant's Name Address Application ID# Telephone Number Landlord/Manager Name Address Telephone Number Are water and or wastewater utilities included in the rent? Are you disconnected for an overdue water or wastewater bill? Are you in danger of disconnection for an overdue water or wastewater bill? Is your water bill past due and more than$250? Landlord/Manager Signature Date LAA VERIFICATION (if applicable) LAA Verified Signature Date Landlord/Manager contacted (if needed) Low Income Household Water Assistance Program LIHWAP WATER AND WASTEWATER UTILITIES INCLUDED IN RENT VERIFICATION Applicant's Name Address Application ID# Telephone Number Landlord/Manager Name Address Telephone Number Are water and or wastewater utilities included in the rent? Are you disconnected for an overdue water or wastewater bill? Are you in danger of disconnection for an overdue water or wastewater bill? Is your water bill past due and more than$250? Landlord/Manager Signature Date LAA VERIFICATION (if applicable) LAA Verified Signature Date Landlord/Manager contacted (if needed) LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM NOTIFICATION LETTER—APPROVAL Date: Applicant's Name: Applicant's Address: Dear Your application for the Low-Income Household Water Assistance Program has been considered and a determination was made that your household is eligible for benefits: A payment will be sent to the following vendor(s) on your behalf. Water Benefit: Vendor Name: Wastewater Benefit: Vendor Name: Your utility bill will reflect when payment has been made. Your full hearing/appeal rights are explained in Your Rights, which you received when you applied. If you would like an additional copy of Your Rights, please let us know. If you have any questions, please contact: Name: Phone Number: We appreciate this opportunity to serve you. Sincerely, Agency Representative: cc:Applicants File LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM NOTIFICATION LETTER—DENIAL Date: Applicant's Name: Applicant's Address: Dear Your application for the Low-Income Household Water Assistance Program has been considered and a determination was made that your household is ineligible because: nYour household's total income was over the allowable limit for your household. Your household already received a benefit for: Water Wastewater 0 Your household did not submit all required documentation and/or information by the required date of nOther: You have the right to appeal this decision by requesting an informal conference at our agencywithin 30 days of the date of this letter by contacting: Your full hearing/appeal rights are explained in Your Rights,which you received when youapplied. If you would like an additional copy of Your Rights, please let us know. We appreciate the opportunity to serve you. Sincerely, (Agent Representative) Cc:Applicant's File SELF-EMPLOYED INCOME WORKSHEET Applicant/Household Member Name Business Address Type of Business Information must be verified by a ledger, check stubs, receipts and/or other verification. A. GROSS RECEIPTS OR SALES B. DEDUCTIONS OF EXPENSES RELATED TO BUSINESS 1. Advertising(flyers, newspaper ads, etc.) 2. Bad debts from sales or service(uncollectable) 3. Bank Service Charges ( bank fees) 4. Business Related Laundry(uniforms,) 5. Cost of Goods Sold (cost of products sold) 6. Insurance (for business only) 7. Interest on business indebtedness (loans, credit cards, etc) 8. Legal and Professional Services (accountant, lawyer, etc) 9. Office Expense(copy paper, pens,sales receipts,etc), 10. Postage(mailing flyers, invoices, receipts, etc) 11. Rent Expense(for business property-does not include mortgage) 12. Repairs(on copy machines,fax machines, computers,etc) 13. Taxes incurred and paid during the timeframe (business related ) 14. Telephone (business related) 15. Transportation Expense (for Program Year 2021,use$.5 per mile for automobile)or include public transportation (bus,train,taxi) 16. Utilities (business) 17. Wages Paid to Employees(Other than Self or Household Members) 18. Other(specify) C. Wages paid to Owner D. Wages Paid to Household Member E. TOTAL EXPENSES (B+C+D) F. NET INCOME A.(GROSS RECEIPTS)minus E. (EXPENSES) = NET PROFIT OR LOSS ***C, D,and F must be reported on income affidavit 1. The Profit or Loss(listed above)from business or professional self-employment is for the 30 day period of to 2. The Profit(or Loss) list above is available to the owner and/or other household members for personal use? YesF—]No 3. 1 certify and declare, under penalties of perjury,that the information I have provided is an accurate and complete disclosure of the requested information. Signature Date REV 9/21 Application#: - 1 PAPER APPLICATION -- -- ❑Illinois Low Income Home Energy Assistance Program (LIHEAP) ❑Illinois Home Weatherization Assistance Program (IHWAP) ❑Low-Income Household Water Assistance Program (LIHWAP) ❑Water ❑ Wastewater ❑ Both Water and Wastewater To contact the Energy Assistance Hotline: (Toll Free) (877)411-9276 To report LIHEAP/IHWAP fraud or abuse: AppID#: Department of Commerce & Economic Opportunity Does Customer bill reflect service from Alternative Supplier?If Yes, Office of Energy Assistance add name of supplier Attn: Fraud Unit, 500 E. Monroe,Springfield, IL 62701 To check the status of your application,please go to www.illinoisliheap.com/status Agency: Intake Site: County: PY: Application Date:__ Service Requested: JOB#: HOH SSN Name Gend Date of Birth Eth Eman Dis Vet Wages SSA Unempl SSI TANF GA Oth DwellingType:SF 2-4 5-10 11+MH GH SRO Rent: $ Totals: 0 0 0 0 0 0 0 Shelter Own: ubH SNAP Veteran Total Income: n REFERRAL: Wx Medicaid SSI Unemployment Nutrition Life Line Safe place_ Child care Energy Cons. Tips Budget Aging Other ADDRESS: Service Address:Street XxX City: Zip — Phone:( - (Home,cell,neighbor,work,etc.) Cell:( 1O"` )- - _(Home,cell,neighbor,work,etc.) Phone2:( - (Home,cell,neighbor,work,etc.) E-Mail: _(E-Mail,neighbor,work,etc.) Mailing Address:Street City 'Lip REV 08/21 Application#: PAPER APPLICATION VENDOR: Vr ih m--a i y Vendor: Secondary Vendor: Prior Weatherization Date_/_/ LIHEAP Furnace Date Client Pays: Med Cert: Client Pays: Med Cert: Re-Determination IHWAP_/_/ Documentation: Rec'd COR: COR: Eligible Due to :50%Rule Rec'd Date Eligible Due to:HTT Eligible Due to : Income Fuel Acct# Fuel Acct# Eligible Due to : LIHEAP Household Income Status Status Eligible Due to :66%Rule_ Household SS#'s Primary Energy Bill _/_/ Secondary Energy Bill /_/ Eligible Due to:Auto Home Ownership / / SUPPLEMENTAL QUESTIONS SUPPLEMENTAL QUESTIONS FOR WATER/WASTEWATER 1. Currently Have a Past Due Notice for Primary Vendor/Main Heating Fuel : 1. Are you currently disconnected for having a past-due Water Bill? 2. Supplemental Heating Fuel (Select one): Yes No 3. Main Cooling Equipment(Choose one): 2. Are you to imminent anger of bein disconnected on a past-due 4. Number of Sleeping Rooms in the Home: Water Bill? Yes rl No 5. A/C Location ( Choose one): 3. Are you currently behind on your water or-wastewater bill in 6. Number of Air Conditioner Units in the Home: amount of$250 or more? Yes No Please read and Sign: IMPORTANT NOTICE:This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under the Low Income Home Energy Assistance Act of 1981 as amended. Disclosure of this information is REQUIRED. Failure to provide any information will result in this application not being processed.This application has been approved by the State Forms Management Center. Applicant Statement: I certify that the information I have provided above is an accurate and complete disclosure of the requested information. I also certify that every household member in the application is either a US citizen or an eligible Illinois resident regardless of immigration status according to the LIHEAP/IHWAP/ LIHWAP rules. I authorize this agency to verify the information and contact my utility/fuel supplier, landlord, employer and/or other sources for verification or additional information and to exchange information contained in or otherwise used regarding my application and participation in LIHEAP/IHWAP/LIHWAP. I also authorize the Department of Commerce&Economic Opportunity and my utility/fuel supplier to share my usage and bill information during the twenty-four(24) month period prior to and twelve(12) month period after the date of my application submittal and/or completion of LIHEAP and IHWAP services for the purpose of program evaluation and analysis. I have received information outlining my appeal rights. I understand that filling out this application does not guarantee that my household will receive assistance. The purpose of this document is to provide a summary of the application to the customer for future reference. Date / / Date_/_/ Signature of Applicant Eligibility Verification/Determination Signature Date / / Date / / Signature of Intake Worker Payment Authorization Signature ❑ I understand all income sources, for all household members, will be further verified by the State of Illinois. Initials Date REV 08/21 Printed by the Authority of the State of Illinois Application #: ---------------- LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM REQUEST FOR FORMAL HEARING Applicant Name: Address: City: Zip: Phone: I have applied for LIHWAP at this Agency: The agency has held an informal conference: YES F� NO ❑ The Department has conducted a State Review and has notified me of their decision: YES ❑ NO ❑ I am requesting a Formal Hearing to be conducted by the State Hearing Officer because (explain below the reasons why you are dissatisfied with the State Review): Applicant/Representative Signature Date Send to: Illinois Department of Commerce and Economic Opportunity Office of Community Assistance 500 East Monroe Street Springfield, IL 62702 REV 09/21 Application#: LIHWAP REQUEST FOR INFORMAL CONFERENCE LIHWAP Applicant/Customer: Application Number: Total Amount Due: In accordance with the determination letter, the undersigned hereby requests an informal conference to determine the facts and issues and to resolve any conflicts as amicably as possible before any formal recovery action is taken. Provide facts/grounds upon which the protest is based. Signature: Printed Name: Date: Address: Telephone Number: Request for an informal conference must be sent to: Attn.. REV 09/21 LOW INCOME HOUSEHOLD WATER ASSISTANCE PROGRAM REQUEST FOR STATE REVIEW Customer's Name: Address: City: Zip: Phone: I have applied for assistance under the Low Income Household Water Assistance Program at the following agency: The Agency has held an informal conference and I have been notified of the outcome of the conference: ❑ YES ❑ NO I request a review by the State regarding the agency's decision on my Energy Assistance Program application because (explain your reasons for requesting a State Review): Customer/Representative Signature Date Send to: Illinois Department of Commerce and Economic Opportunity Office of Community Assistance 500 E Monroe St. Springfield, IL 62701 REV 09/21 VENDOR AGREEMENT This agreement, dated as of ,20XX, is entered into by and between , (Agency),and a supplier of home water and/or waste water, (Vendor). PURPOSE Public Law No: 116-260 signed on December 27,2020, included funding with instructions for the Administration for Children and Families(ACF)within the U.S. Department of Health and Human Services(HHS)to carry out grants to assist low-income households, particularly those with the lowest incomes,that pay a high proportion of household,income for, drinking water and wastewater services, by providing funds to owners or operators of public water systems or treatment works to reduce arrearages of and rates charged to such households for such services.This act requires that certain assurances be satisfied before assistance payments are made, on behalf of eligible individuals,to suppliers of drinking water and wastewater.This agreement defines the conditions that the Vendor must agree to so that the Agency can make assistance payments to the Vendor on behalf of eligible households. AGENCY RESPONSIBILITIES The Agency shall: • Accept and review client applications and determine eligibility of households for payments. • Submit applications subject to available funding to the Department for eligible households according to LIHWAP guidelines. • Follow procedures that minimize the time elapsing between the receipt of funds and their disbursement to vendor. • Make payments in a timely manner to the vendor on behalf of eligible households for the term of this agreement. • Follow sound fiscal management policies, including, but not limited to segregation of funds from other operating funds of the agency. • Notify customer and/or vendor of the customer's eligibility and total benefit amount. • Incorporate policies that assure the confidentiality of eligible household's usage, balance,and payments. VENDOR RESPONSIBILITIES The Vendor shall: • Provide an invoice that clearly states the cost of the water and/or wastewater service and fees only. • Accept benefit checks and vouchers on behalf of eligible households for the purpose of providing LIHWAP services for customers identified to receive such benefits. • Immediately apply the benefit payment to customer's current/past due bill, deposit/reconnect requirements, late fees, or arrearages to eliminate the amount owed by the customer for a period determined by the amount of the benefit. • Notify the customer of the amount of benefit payment applied to the customer's billing. • Refund any payments made in error to the LIHWAP agency who made the payment on behalf of the customer. • Keep customer records confidential. • Maintain records for four(4)years from the date of this agreement,or longer if the vendor is notified that a fiscal audit for a specific program year is unresolved. • Make records available for review by authorized staff of the Department of Commerce and Economic Opportunity,Office of Community Assistance. I REQUIRED RECORDS FOR AUDIT PURPOSES • The vendor will keep records showing the following: • Name and address of households who received assistance payments. • Amount of assistance to each household. • Source of payment. OTHER PROVISIONS Term of Agreement This agreement is effective from the date of execution. Termination This agreement may be terminated by either party with a thirty(30) day written notice to the other party.Termination shall not extinguish authorized obligations incurred during the term of the agreement. If funding is withdrawn, reduced, or eliminated by Commerce,the agency has the right to terminate this agreement immediately. Assignment of Agreement Neither party may assign the agreement or any of the rights, benefits and remedies conferred upon it by this agreement to a third party without the prior written consent of the other party,which consent shall not be unreasonably withheld. The vendor and the agency do hereby agree to the conditions set forth in this agreement. Agency Signature Date Printed Name Name of Company Vendor Signature Date Printed Name Name of Company The date of this agreement is September 1,2021 through September 30,2023 VENDOR AGREEMENT This agreement, dated as of J is entered into by and between , (Agency),and , a supplier of home water and/or waste water, (Vendor). PURPOSE Public Law No: 116-260 signed on December 27,2020, included funding with instructions for the Administration for Children and Families (ACF)within the U.S. Department of Health and Human Services(HHS)to carry out grants to assist low-income households, particularly those with the lowest incomes,that pay a high proportion of household income for drinking water and wastewater services, by providing funds to owners or operators of public water systems or treatment works to reduce arrearages of and rates charged to such households for such services.This act requires that certain assurances be satisfied before assistance payments are made, on behalf of eligible individuals,to suppliers of drinking water and wastewater.This agreement defines the conditions that the Vendor must agree to so that the Agency can make assistance payments to the Vendor on behalf of eligible households. AGENCY RESPONSIBILITIES The Agency shall: • Accept and review client applications and determine eligibility of households for payments. • Submit applications subject to available funding to the Department for eligible households according to LIHWAP guidelines. • Follow procedures that minimize the time elapsing between the receipt of funds and their disbursement to vendor. • Make payments in a timely manner to the vendor on behalf of eligible households for the term of this agreement. • Follow sound fiscal management policies, including, but not limited to segregation of funds from other operating funds of the agency. • Notify customer and/or vendor of the customer's eligibility and total benefit amount. • Incorporate policies that assure the confidentiality of eligible household's usage, balance,and payments. VENDOR RESPONSIBILITIES The Vendor shall: • Provide an invoice that clearly states the cost of the water and/or wastewater service and fees only. • Accept benefit checks and vouchers on behalf of eligible households for the purpose of providing LIHWAP services for customers identified to receive such benefits. • Immediately apply the benefit payment to customer's current/past due bill,deposit/reconnect requirements, late fees,or arrearages to eliminate the amount owed by the customer for a period determined by the amount of the benefit. • Notify the customer of the amount of benefit payment applied to the customer's billing. • Refund any payments made in error to the LIHWAP agency who made the payment on behalf of the customer. • Keep customer records confidential. • Maintain records for four(4)years from the date of this agreement,or longer if the vendor is notified that a fiscal audit for a specific program year is unresolved. • Make records available for review by authorized staff of the Department of Commerce and Economic Opportunity,Office of Community Assistance. REQUIRED RECORDS FOR AUDIT PURPOSES • The vendor will keep records showing the following: • Name and address of households who received assistance payments. • Amount of assistance to each household. • Source of payment. OTHER PROVISIONS Term of Agreement This agreement is effective from the date of execution. Termination This agreement may be terminated by either party with a thirty(30) day written notice to the other party.Termination shall not extinguish authorized obligations incurred during the term of the agreement. If funding is withdrawn,reduced, or eliminated by Commerce,the agency has the right to terminate this agreement immediately. Assignment of Agreement Neither party may assign the agreement or any of the rights, benefits and remedies conferred upon it by this agreement to a third party without the prior written consent of the other party,which consent shall not be unreasonably withheld. The vendor and the agency do hereby agree to the conditions set forth in this agreement. Agency Signature Date Printed Name Name of Company Vendor Signature Date Printed Name Name of Company The date of this agreement is September 1,2021 through September 30,2023 Clear Form, Universal Signature Page IMPORTANT NOTICE: This state of Illinois grantee agency is requesting disclosure information that is necessary to accomplish a complete application for: ® Community Service Block Grant (CSBG) Illinois Home Weatherization Program (IHWAP or ■ eatherization) Low Income Home Energy Assistance Program (LIHEAP or Energy Assistance), including the Percentage of Income Payment Plan (PI PP) program Low Income Household Water Assistance Program (LIHWAP or ® Water — Wastewater Program) APPLICANT STATEMENT: I certify that the information I have provided is an accurate and complete disclosure of the requested information. I also certify that every household member in the application is a resident of Illinois. I authorize this agency to verify the information and contact my utility/fuel supplier, landlord, employer and/or other sources for verification or additional information and to exchange information contained in or otherwise used regarding my application and participation in CSBG/LIHEAP/IHWAP/LIHWAP. For LIHEAP and IHWAP I also authorize the Department of Commerce & Economic Opportunity and my utility/fuel supplier to share my usage and bill information during the twenty-four (24) month period prior to and twelve (12) month period after the date of my application submittal and/or completion of LIHEAP and IHWAP services for the purpose of program evaluation and analysis. I have received information outlining my appeal rights. I understand that filling out this application does not guarantee that my household will receive assistance. I understand I will be provided a copy of this application for my future reference. Applicant Name: Applicant Signature: Date: APP ID: CLEAR FORM Universal Signature Page (Proxy) IMPORTANT NOTICE: This state of Illinois grantee, ("Agency"), is requesting disclosure of information that is necessary to accomplish a complete application for: Illinois Home Weatherization Assistance Program (IHWAP or Weatherization) Low Income Home Energy Assistance Program (LIHEAP or Energy ® Assistance), including the Percentage of Income Payment Plan (PIPP) ® program Low Income Household Water Assistance Program (LIHWAP) APPLICANT STATEMENT: I certify that the information I have provided is an accurate and complete disclosure of the requested information. I also certify that every household member in theapplication is a resident of Illinois. I authorize this agency to verify the information and contact my utility/fuel supplier, landlord, employerand/or other sources for verification or additional information and to exchange information contained in or otherwise used regarding my application and participation in LIHEAP/IHWAP. For LIHEAP and IHWAP I also authorize the Department of Commerce &Economic Opportunity and my utility/fuel supplier to share my usage and bill information during the twenty-four(24) month periodprior to and twelve (12) month period after the date of my application submittal and/or completion of LIHEAP and IHWAP services for the purpose of program evaluation and analysis. I have received information outlining my appeal rights. I understand that filling out this application does not guarantee that my household will receive assistance. I understand I will be provided a copyof this application for my future reference. Applicant Name: Applicant Signature: Date: Proxy Name: Phone: Relationship to Applicant: Proxy Signature: Date: PROXY STATEMENT: I certify that the applicant named above has given me permission to actas the Authorized Proxy and take the following actions on the applicant's behalf for LIHEAP and/or IHWAP programs: complete an application, speak with Intake Site staff and/or other Agency staff regarding my application as well as any follow up required as it relates to my application. THIS FORM MUST BE RETURNED BY: Application Number: Low Income Household Water Assistance Program Verification of Assistance Paying Household Bills (This means someone has paid a bill directly for you) If you have received cash directly from any individual for these expenses, please STOP and complete the Income Affidavit. Cash gifts are considered "unearned income" and need to be reported on the Energy Assistance Income Affidavit. To Whom It May Concern: I, , (print name of person assisting with household bills) have paid the following expenses directlyto the Landlord, Mortgage or Utility Company(or other) during the 30 day period covering to for (print name of applicant) Please fill in the dollar amount that applies: $ Heat/Electricity $ Rent $ Food $ Water $ Transportation $ Other—Please detail: $ TOTAL I certify the information provided above is true and a complete statement of facts. I understand I may be required to provide proof of any information given. False information will invalidate this form and may require the return of any benefits received based on the false information. Name: (Signature) (Date) Address: Phone Number: REV 9/21 Application#: Water Bill Pledge for the Low Income Household Water Assistance Program TO: Vendor Name: Vendor Address: Vendor Phone Contact Person: Vendor Contact Person: Vendor FEIN: FROM: Agency Name: Agency Address: Agency Phone: Agency Contact Person: RE: WATER BILL PLEDGE Customer Name: Customer Address: Customer Account Number: Pledge Amount: Water Utility Status: ❑ Disconnected Service ❑ Imminent Disconnection ❑ Household with Past Due Arrearages Over$250 Water Utility Assistance: ❑ Water Only ❑ Wastewater Only ❑ Both Water and Wastewater The above-named customer has applied for assistance to restore their water service or avoid disconnection. Please restore all disconnected services as soon as possible. Customers who have service but owe arrearages should be processed within the amount of time required to stop disconnection and avoid further late fees. This household has been approved for a payment of$ and will be sent within the next business days. Date: Water Bill Pledge for the Low Income Household Water Assistance Program TO: Vendor Name: Vendor Address: Vendor Phone Contact Person: Vendor Contact Person: Vendor FEIN: FROM: Agency Name: Agency Address: Agency Phone: Agency Contact Person: RE: WATER BILL PLEDGE Customer Name: Customer Address: Customer Account Number: Pledge Amount: Water Utility Status: ❑ Disconnected Service ❑ Imminent Disconnection ❑ Household with Past Due Arrearages Over$250 Water Utility Assistance: ❑ Water Only ❑ Wastewater Only ❑ Both Water and Wastewater The above-named customer has applied for assistance to restore their water service or avoid disconnection. Please restore all disconnected services as soon as possible. Customers who have service but owe arrearages should be processed within the amount of time required to stop disconnection and avoid further late fees. This household has been approved for a payment of$ and will be sent within the next business days. Date: Page 1 Low Income Household Water Assistance Pro ram Zero Income Affidavit U'Saet 111 7�' Income Period: Name of adult mem'ber(s)with Zero Income: Last date of Date of Last From: To: Application#: Head of Household Name: The dates may not be in the 30-day timeframe,but"Last date of Employment"and"Date of Last Pay"must be entered for each adult with zero income. 1. Have any of the above-listed household members received cash or check(s)as payment for work performed in the last 30 days?*Example:hair styling,babysitting,lawn/snow maintenance,car repair,scrap metal,etc. ❑Yes* ❑No Continue to question 2 *If yes,the person is not a Zero Income Adult. 2. Have any of the above-listed household members received any cash gifts in the last 30 days?*Example:A friend or relative gives you$50 this month as a gift to help with your living expenses. ❑Yes* ❑No Continue to question 3 *If yes,this is considered"unearned income";therefore,the person is not a Zero Income Adult 3. Have any of the above-listed household members received any loans in the last 30 days?*Example:A friend or relative loans you money this month to help with your living expenses. ❑Yes*CONTINUE ❑No Continue to question 4 *If yes,this is not considered income,but is assumed as a debt to be paid back at a later time;therefore,the recipient may be considered a Zero Income Adult Please indicate below the amount of the loan,and the name of the person assisting you,then continue to question 4. Amount of Loan: Per�son:As MSUMa � Amy cunt ofiLoari - Person Assisting " I RSs..s�'1dP3. '�Y14F�^&h'�'r".,a:ere,:.dc_wn- 4. Does any person or agency pay any ofyour expenses,such as rent,mortgage,utilities,directly to the landlord, mortgage or utility company? ❑Yes*CONTINUE ❑No Continue to signature ❑All Expenses were covered by household's recorded income. If yes,continue filling out this form and indicate which expenses were paid directly and by whom. Please include the 30-day expense totals,and explain below how the following expenses have been met in the household(such as SNAP,Section 8,etc.). If paid for directly by someone else,please indicate the name of the person assisting,and complete the Verification of Pavinar Household Bills Affidavit,in addition to the Zero Income Affidavit. If a cash gift is received,see#2(above). Type of Expense Amount IN M M m How w,as they need met? Name of person assistinol g directly, Food Housing Transportation Utilities Basic living needs* *Example: clothing,diapers,cleaning supplies,personal hygiene products,etc. I certify the information provided above is true and a complete statement of facts. I understand: I maybe required to provide proof of any information given. False information will invalidate this form and may require the return of any benefits received based on the false information. I understand all adult household members are subject to further verification of the income information provided. This form must be completed in full or my application will be DENIED. Assistance was needed to fill out this form: ❑Yes ❑No Applicant Signature Date Intake Worker Signature Date Revised 9/21