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COVID Supplemental LIEAP Benefit Request Form
Head of Household field MUST be entered exactly as application
Head of Household First Name
Head of Household Last Name
Head of Household Service Street Address
Last 4 Digits of SSN
Current household member’s names (Please submit identification for any new household members) :
Work hours within my household have been reduced due to COVID-19
(Please submit most recent paystub showing reduced hours for each household member effected.)
Names of household members whose hours have been reduced:
Household members have been laid off or furloughed due to COVID-19
(Please submit proof for each household member effected. Examples include: unemployment letter or letter from employer.)
Names of household members who have been laid off