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Employment Denial Letter Samples

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					             Manager’s Guide to LIHEAP FFY09 Eligibility Workbook                                                              NOTE:        A late change in process. Se the discussion of
                                                                                                                               "Estimated EA Benefit Amount" below. It is a change in which
       1. Setup has not changed from previous version - see below for details.                                                 cell triggers the EA benefit amount to show. By changing it to
       2. This workbook will detrmine LIHEAP eligibility, including the new 135% guidelines, but is for use                    Heat Code, at the top of the sheet, the whole vendor section
           after the EA program has closed, March 31st, so EA Amount just says N/A.                                            can be skipped if there is no crisis - just a normal LIHEAP
                                                                                                                               eligibility. this is also explained in a note o the User's guide
                                                                                                                               on the next tab.
                                                Setup, and New Features
The new workbook contains several new features designed to make working applications easier, faster, and more
accurate. Key elements are it figures the applicant’s Percent of Poverty, and it automatically figures and displays the
Estimated EA Benefit Amount.
The new LIHEAP Workbook includes 10 tabs, as follows.
1. Managers instructions – You're on that tab now. It was also sent as a Word document.
2. Users Guide– It's next to this one. (A user’s guide was also provided in Word.)
3. “Denial Codes” tab – which also includes drop down lists for you to complete. They are in black boxes, including
rows included in the list.
      a. “Source Drop-down List” where you can add to the fund sources already there for additional fund
      sources you may be using to meet crisis. (Currently includes EFSP, Dollar-Help, -Dollar More, MHTF (MACA), Later Changes 10-5-07 - See User Guide at
      and Other. Any or all can be replaced by your fund names.                                                  top right.
      b. “County Names” – replace sample names with your counties.
      c. “User ID” – Replace the samples - enter the current Sate User IDs of your staff.                                      NEWEST CRITICAL CHANGE - 10-10-07.
      d. “Agency Name’ and address – this one is new and feeds the new vendor pledge letters.                                  See User Guide for explanation. This
4. “Vendors” – This tab hasn’t changed, but you’ll need your two vendor lists – one with the name and address of all           worksheet is named (v9.0)
your current vendors, and one with the vendor name followed by their State Vendor number. (On the second list, be
sure to preserve the standard ones, and replace the bogus example ones.) Be sure you’ve updated these for the new
year. Both lists are needed for different drop-downs on the worksheet.
5. “EA 1A Worksheet Pg 1” Requires no action, and hasn’t changed except for the new “Clear Workbook” button at
the top of the page and being re-named LIHEAP instead of EA, and includes the program year.
6. “EA-1A Worksheet Pg 2” Requires no action, but has had several changes explained later in this text.
7. “Prim. Pledge” – A pledge letter that can be printed and faxed, or copied and emailed, to a vendor when there is a
crisis at the time of figuring eligibility involving the PRIMARY fuel source. It will also include any EA, ECIP, and
other funds being pledged to meet the primary fuel crisis. The letter displays each fund and amount, and totals them.
8. “2ndary Pledge” – a pledge letter that can be printed and faxed, or copied and emailed, to a vendor when there is a
crisis at the time of figuring eligibility, but for a SECONDARY fuel source. On this one the Estimated EA amount does
not appear, but the others do. The letter displays each fund and amount, and totals them. (NOTE: Everything on each
Pledge Letter appears on the page automatically – except the client’s address, which isn’t on the worksheets. So
the Address is all the staff needs to enter to use the pledge letters. When finished, the “Clear Button” on page one also
deletes these client address entries.)
9. “Pov. % Calc.” – (This tab is hidden.) It contains a poverty guideline chart, and calculations related to data on the
worksheets. It enables several things. First it calculates the household’s percent of poverty. The result is displayed on
page 2. If they are income eligible, it displays near the “Approve” box, and if they are over income it will display near
the “Deny” box, in red.
10. “EA Ben. Calc.” – (This tab is hidden.) It contains the entire income ranges, and fuel-type benefit ranges in the
LIHEAP manual, and through numerous calculations derived from data entered on the Worksheet, arrives at the correct
EA benefit amount, where Page 2 picks it up. This should cumulatively save quite a bit of time, and increase accuracy.
EA 1A Worksheet pg 1:
    Little has changed on page 1 of the worksheet. There is a new "Clear Workbook" button at the top of page 1.
    The button does not print when the page is printed. This eliminates the keyboard keys to clear the data, and any
    confusion about which page to be on when clearing. When the button is used, all applicant data entered is deleted,
    and it ends on the first cell that would be entered on Page 1 - "County" - ready for the next client.
EA 1A Worksheet Pg 2 has a number of changes.
      Supplier names: There is a third line for a Supplier name/address. So now they are:
           1. PRIM. SUPPLIER NAME, ADDRESS: for the supplier of the primary heating fuel. (vendor drop
           down list)
           2. 2NDARY SUPPLIER (ECIP ONLY): For the supplier of a secondary fuel source if there is also a
           crisis with that source at the time of figuring eligibility. (vendor drop down list)
           3. (Type vend. & Address if not on list.): has always been there for entering a vendor name and address if
           it isn’t in the vendor drop-down list. This will work for either Primary or Secondary vendor purposes – but the
           workbook can’t handle both not being on the drop down list, so try to keep your vendor list up to date.
      These should be used any time there is a crisis at the time LIHEAP eligibility is being determined. Doing this gives
      you a record of the vendors involved, AND enables the two pledge letters that are new features. There would be a
      problem if the primary and secondary were both being used, and neither was a drop-down choice, so keep your
      vendor lists current.
      Vendor Contact Details: There are now two sets of fields for Customer Acct. #, Date Supplier Contacted, Person
      Contacted, and Supplier Response. One set for the Primary Supplier, and one for the Secondary. This gives you a
      record of what happened with each, and the Account # and Date contacted report to the appropriate vendor letter.

      Approve / Deny check boxes: These are now locked, and will display properly automatically for approved or
      denied applications when the data is complete. They cannot be typed in.
      Percent of Poverty: (NEW) This can appear in two places. If they are within the income guidelines, the percent
      of poverty will display to the right of the Approve check-box. If they are over the income guidelines, it will display
      to the right of the Deny check-box – in red. (If the applicant is denied for reasons other than income, it will affect
      the Approve/Deny check boxes, but not the poverty % display. In addition to providing a record of the applicant’s
      % of poverty, the bold red for the over income will alert staff to deny the application, using the drop-down.
      Estimated EA Benefit Amount: The correct EA benefit amount will appear in the cell once the income, # in HH,
      and “HEAT CODE” are known. The cell is locked.
      Obligated ECIP Amount: There are now two places to enter an ECIP obligation – one for the Primary fuel
      supplier, and one for the Secondary fuel supplier. This enables the pledged amounts to show up on the right
      Pledge letter, so workers must be sure to use the correct box for the pledge.
      Under “Payment Amounts From Other Funding Sources” there are some changes.
             The default “Source” dropdowns (from the Denial Code tab sheet ) has changed FEMA to the correct
            “EFSP”, and changed DFS/EA, which doesn’t apply here, to MHTF/MACA, which was missing. (On the
            drop down list on the denial page you may want to add more funds you have.)
            The fourth field in each row is changed to “Fuel Type”, and is a dropdown to indicate whether this is a
           primary or secondary fuel source. Again, this is so each Pledge letter picks up the appropriate information.

      Page 2 also has a warning message that appears in bold red if the amount of resources on page 1 totals more than
      $3000. It prompts the user to deny them using the drop-down list. When the application is denied for any reason,
      the warning message will disappear.

The Vendor Pledge letters
    These are almost entirely automatic. Only the client’s address needs to be added.
    If the vendor wants something faxed, the letters are set to print, and your agency name and address are at the top –
    (from the entry you made in on the “Denial Codes” tab sheet.
    If the pledge can be emailed to the vendor, just highlight the letter with the mouse – (probably sopping before the
    signature line) – and right-click the mouse and choose “Copy”, and start an email to the vendor – right-click in the
    body of the email, and choose “Paste.” Then send it.
The old “ECIP” tab, where the whole sheet was only to generate an ECIP application, was removed as no longer
needed.
Be sure to train your staff in the changes to the workbook. A users guide is included, that will

Tips about how to save for your staff:
      1. When you save the file, give it a new name for your agency – instead of “Kit.”
      2. When you want to make changes without having to re-name the file, open it by saying “No” to the question
      about opening as “Read Only.”
      3. If you want less clutter for your staff, and would like to hide things like manager guide, Denial Codes, and
      Vendors, with the tab open you want to hide, go to “Format” in the menu bar, select “Sheet”, and then click on
      “Hide.” To display hidden tabs, or sheets, go to the same place and click "Unhide." You'll get a list of hidden
      sheets and can choose what you want to display. If you’ve hidden the Vendors tab, you can display it this way for
      editing changes. (You could view the calculation sheets this way, but they are locked and protected.)
      4. When saved, a workbook opens to the page, or tab, you were on when you saved it, so if you save it on Page 1,
      that will be the first page users will see when they open it. You can tell them about the “Users guide” tab but give
      them the User’s guide Word document as well.

If you have problems, or any questions, contact Paul Clark at (417) 256-6147, or by email at
       pclark@oaiwp.org
    2. The income guidelins match the current FFY09 chart, including the 135% range.                                   (See red note below for l
    3. Otherwise, the instructions below from prior years applies.
The new LIHEAP Worksheet for FFY08 should make the process easier, more efficient, and improve accuracy. Later changes (10-5-07) Page
The purpose of this guide is to describe the main changes, and what’s different in using it.             to report whether service is "Threa
                                                                                                                       both Primary and Secondary suppl
EA-1A Worksheet Pg. 1:
    This page is very little different from in the past. The main difference is at the top of the page you’ll see a    Also - There is a "Print" button loca
    button labeled “Clear Workbook.” When you’re finished with an application, and have printed                        at the bottom of pg. 2.. Clicking on
                                                                                                                       2, and returns you to the top of pag
    everything you need, (or saved them as PDF documents if your agency is “paperless”), clicking that button
                                                                                                                       Workbook button is located. (Pled
    will erase everything you’ve put in, and return you to the “County” cell at the top of page 1, ready for the       automatically printed, so if you nee
    next application.                                                                                                  before you clear.)
EA-1A Worksheet Pg. 2: Most of the changes to the Worksheets are on this page.                                         NEW 10-10-07   Disregard eve
    Entering Vendors:                                                                                          poverty messages. (The States's
       There are two drop-down fields for entering vendors, and one open to typing. They should be used any    125%, and by different amounts by
                                                                                                               eligibiilty by % of poverty had to be
       time the applicant is in crisis at the time of determining eligibility, even if it will only take EA to solve
                                                                                                               the % of poverty it will simply say "
       the crisis. (See Screen shot.) The information will be
                                                                                                               adjusted income is at or below the
           1. The first is for the Primary Fuel vendor.                                                        HH size. If they are not eligible, th
           2. The second is for the Secondary Fuel Vendor. This one applies only when ECIP, or other           warning will be displayed, and will
           funding sources are being used to meet a crisis at the same time as the LIHEAP application is being denial codes have been selected,
           processed. (Of course EA can’t pay for a secondary heat source.)                                    Deny box.
           3. There is a third line for vendor information that isn’t in the drop-down vendor list. Such
           vendors may not be needed, especially for EA, and may not even be known – as for example Wood
           dealers, or other sources where the vendor is not contracted with the State, and the EA check will go
           to the Applicant. (See below)

                                                                                                                       NOTE: A late change in process. T
                                                                                                                       shown at the left is for use when th
                                                                                                                       using either EA, or ECIP, or both. T
                                                                                                                       automatic EA Benefit is tied to the
                                                                                                                       here - and it was. But it's been CH
                                                                                                                       CODE" at the top of the form. It's t
                                                                                                                       if there is no crisis, you don't need
                                                                                                                       section of page 2 shown at the left
                                                                                                                       people are used to for non-crisis L
    “Heat Source”: There is one drop-down list for the Primary, and one for the Secondary heat source.
    These are not new, but may have been thought of only for ECIP purposes. Now it is necessary to answer
    the Primary one for EA, and the Secondary one only if crisis payments are being made to the Secondary
    vendor. (We’ll get to the reasons shortly.)
    Customer Account/Contact information: Since potentially two different venders may be pledged to,
    when there is a crisis with both Primary and Secondary fuels, there are now fields for Act. #, date the
    supplier is contacted, and the contact name, as well as yes/no response fields for both. (See below)




    The Approve / Deny boxes are locked. The worksheet will calculate the applicant’s eligibility for the
    program, and it defaults to “Approve.” If for any reason the applicant is denied, the “X” will instead show
    in the Deny box, regardless of income. You must still choose the denial reason from drop-down.
    The household’s Percent of Poverty appears to the right of the Approve box. (See screen shot.) If the
    household were over income, the Percent of Poverty would appear to the right of the Deny box, and
    would be in bold red. Also, a warning will appear prompting you to deny using the drop-down denial box.
    When you do the X will move to the Deny box, and the warning message will disappear.
                                                           Page 2 of 22
The “Estimated EA Benefit Amount” will fill automatically from calculations on a separate page. Once
the Adjusted Income, the Primary Fuel type, and the number in the household are known, the correct
Estimated EA Benefit Amount will appear. (No need to consult the chart – it’s built in.) In this example
all that was entered was a name, an income ($800 after adjustments), Natural Gas as the Fuel Type, and
that there are 2 in the household. The benefit amount returned was $227. (The sheets that contain the
LIHEAP eligibility, and EA Benefit charts and calculations are hidden, but you'll se the results on the
page.)




“Obligated ECIP Amount:” Aside from the name change to Obligated, there are TWO fields for amounts.
If paying ECIP for the Primary heat source, because the EA wouldn’t solve the crisis, put the pledged
amount in the first field, for the Primary Vendor. If, because of a crisis at the same time for the Secondary
heat source, you’re using ECIP for that, put the pledged amount in the second field. This enables
obligating ECIP funds to both the Primary and Secondary vendors, if there is a crisis with both at the time
of doing LIHEAP eligibility.
The very bottom of the page looks much the same. This is where additional funds used to meet a crisis
can be recorded. Some of you may not be accustomed to making use of it, but doing it now will have a
benefit because of the new Pledge letters discussed below.
    Source 1, and 2 are drop down lists that should included the standard funds at your agency that could
    be used. Dollar Help, Dollar More, EFSP, MHTF/MACA, and so on. Source 3 is not a drop-down,
    but can be used for any of the above, or use for one that’s not on the list.
    The field on the far right has been changed to Fuel Type, and again is the choice of either Primary
    Source, or “2ndary source.” (See below.)




                                                      Page 3 of 22
When you’ve entered everything, you’re through with the worksheet, and are ready to print, or save as PDFs,
depending on your agency.
    But many vendors want something
showing what you’re pledging, and for
what client. So there are two pledge
letters on the next two tabs - One to the
Primary vendor and one to the Secondary
vendor. is why all the separation of
    Here
Primary and Secondary sources. All the
information on this letter came from the
worksheet. The amount being pledged to
the vendor, from each source is shown,
and totaled. Only the applicant’s address
is blank, and an error shows because of
that. The ERROR message will disappear
as soon as the address is entered.
    The Secondary letter shows no funds
because there wasn’t anything pledged for
a secondary heat source.
    This letter can be printed – on agency
letterhead if you like – and faxed to the
vendor. Or, you can copy the letter
portion of the page, and paste it into an
email to the vendor.

   When all is printed (or saved as a PDF
for those doing that) and done you’re
ready to work on the next application.
Just go back to page 1, and at the top click
on the “Clear Workbook” button.
Everything you entered will be gone and
the workbook is blank.




                                                         Page 4 of 22
LIHEAP APPLICATION DENIAL CODES (The choices in drop-down menu on the form.)

A - TOTAL HOUSEHOLD INCOME EXCEEDS THE MAXIMUM ALLOWED FOR YOUR HOUSEHOLD
B - YOU FAILED TO PROVIDE, IN A TIMELY MANNER, ALL OF THE INCOME INFORMATION NEEDED TO ESTABLISH ELIGIBILITY.
C - YOU FAILED TO PROVIDE, IN A TIMELY MANNER, FUEL SUPPLIER INFORMATION.
D - YOU FAILED TO PROVIDE, IN A TIMELY MANNER, SOCIAL SECURITY NUMBER DOCUMENTATION.
E - YOU FAILED TO PROVIDE, IN A TIMELY MANNER, DOCUMENTATION OF A CUSTOMER ACCOUNT NAME CHANGE.
F - YOU FAILED TO PROVIDE, IN A TIMELY MANNER, RESOURCE INFORMATION NEEDED TO ESTABLISH ELIGIBILITY.
G - YOU FAILED TO SIGN AND RETURN YOUR APPLICATION FORM.
H - YOU FAILED TO ADEQUATELY EXPLAIN HOW YOUR HOUSEHOLD HAS MANAGED ON LOW OR NO INCOME.
I - YOU FAILED TO PROVIDE, IN A TIMELY MANNER, DOCUMENTATION OF PERMANENT RESIDENT ALIEN STATUS.
J - TOTAL HOUSEHOLD RESOURCES EXCEED $3000.
L - YOU ARE NOT LIVING IN YOUR HOME AT THE TIME OF APPLICATION.
M - YOU ARE LIVING IN PUBLIC SUBSIDIZED HOUSING AND NOT PAYING SEPARATE HEATING COSTS.
N - YOU CUT YOUR OWN WOOD.
O - YOU USE COAL TO HEAT YOUR HOME.
P - YOU ARE A ROOMER, BOARDER OR LIVE-IN ATTENDANT.
Q - YOU ARE INCARCERATED.
R - YOU ARE NOT A U.S. CITIZEN OR A PERMANENT RESIDENT ALIEN.
S - LANDLORD FAILED TO RESPOND
Vendor Names & Addresses
                                                                       (Blank line)
AA PROPANE, P.O. BOX 372, VERSAILLES, MO
ABSOLUTE HEATING & COOLING, 2703 BRAEMORE ROAD, COLUMBIA, MO
AG CO-OP SERVICES, RFD #1, HWY 87, BOONVILLE, MO
ALL STAR GAS, 1654 HWY 28, OWENSVILLE, MO
ALL WEATHER PROPANE, P.O. BOX 103, CENTRALIA, MO
AMEREN U.E., P.O. BOX 66881, ST. LOUIS, MO
AMERIGAS, 2727 WEST MAIN, JEFFERSON CITY, MO
AQUILA, INC., P.O. BOX 219703, KANSAS CITY, MO
BALLENGER PROPANE, 3250 N. GLENDALE, COLUMBIA, MO
BOONE COUNTY OIL CO., P.O. BOX 615, COLUMBIA, MO
BOONE ELECTRIC CO-OP, 1413 RANGELINE, COLUMBIA, MO
CALLAWAY ELECTRIC, P.O. BOX 250, FULTON, MO
CALLAWAY PROPANE, P.O. BOX 250, FULTON, MO
CAPITAL ENERGY CO., 12610 RENZ FARM ROAD, JEFFERSON CITY, MO
CENTRAL HTG & COOLING, INC., 625 NORTH STURGEON, MONTGOMERY CITY, MO
CHAPMAN HEATING & AC, 4441 I-70 DRIVE, NW, COLUMBIA, MO
CITY OF BLACKWATER, 125 MAIN STREET, BLACKWATER, MO
CITY OF CALIFORNIA, 103 VERSAILLE, CALIFORNIA, MO
CITY OF CENTRALIA, 114 S. ROLLINS, CENTRALIA, MO
CITY OF COLUMBIA, 701 E. BROADWAY, COLUMBIA, MO
CITY OF FULTON, P.O. BOX 787, FULTON, MO
CITY OF VANDALIA, 200 EAST PARK, VANDALIA, MO
CLARKS FIREWOOD, 103 MISSOURI S., HIGBEE, MO
CO-MO ELECTRIC, P.O. BOX 220, TIPTON, MO
COLUMBIA PROPANE, 814 W. WASHINGTON ST., VANDALIA, MO
CONSOLIDATED ELECTRIC, P.O. BOX 540, MEXICO, MO
CONSOLIDATED ENERGY, P.O. BOX 797, COLUMBIA, MO
CONSOLIDATED PWSD #1, 1500N. 7TH ST., COLUMBIA, MO
DACOTT INDUSTRIES, INC., 5001 BISSONNET SUITE 200, BELLIARE, MO
DICKNEITE OIL CO., P.O. BOX 68, FREEBURG, MO
EMPIRE GAS, MO
ERNIE OVERSTREER, 401 MEADOWLARK LN., FULTON, MO
FARM & HOME PROPANE, P.O. BOX 142, BUNCETON, MO
FAYETTE UTILITIES, 117 SOUTH MAIN, FAYETTE, MO
FERRELL GAS, 3901 WACO RD., COLUMBIA, MO
FORDYCE ELECTRIC, PO BOX 106093, JEFFERSON CITY, MO
FRAME OIL, P.O. BOX 815, FULTON, MO
G.A. PROPANE, INC., P.O. BOX 32, KINGDOM CITY, MO
GARSTANG GAS COMPANY, HCR 3 BOX 9, BELLE, MO
GAS AND SAVE PROPANE, P.O. BOX 142, BUNCETON, MO
GASCO, P.O. BOX 71, ELDON, MO
GLASGOW PROPANE, 41096 HWY 5, GLASGOW, MO
GYER GAS, 511 6TH ST., BOONVILLE, MO
HASLAG ENERGY COMPANY, HCR 64, BOX 91, LOOSE CREEK, MO
HAWKINS PLUMBING & HTG., 300 Ravine, Fulton, MO
HENDERSON OIL CO., P.O. BOX 1, COLUMBIA, MO
HOWARD ELECTRIC & PROPANE, MO
JOHNNY SIMONIN, 5336 State Road JJ, Fulton, MO
JORDAN WILLIAMS, P.O. BOX 54, PILOT GROVE, MO
KANSAS CITY POWER & LIGHT, 1715 COMMERCE DR., MARSHALL, MO
KNOERR PROPANE, P.O. BOX 76, LINN, MO
L & S PROPANE, 305 NORTH MILL ST., JAMESTOWN, MO
LANG GAS COMPANY, HIGHWAY 5 NORTH, NEW FRANKLIN, MO
LOCKS MILL PROPANE, P.O. BOX 83, LOOSE CREEK, MO
LUEBBERING OIL CO., 11449 US HWY 63, HARTSBURG, MO
MARY LOU OBRIEN, P.O. BOX 25, ROCHEPORT, MO
MFA - CALIFORNIA, P.O. BOX 388, CALIFORNIA, MO
MFA - CHAMOIS, P.O. BOX 188, CHAMOIS, MO
MFA - COLUMBIA, 2507 N. STADIUM, COLUMBIA, MO
MFA - ELDON, P.O. BOX 187, ELDON, MO
MFA - FULTON, P.O. BOX 526, FULTON, MO
MFA - HERMANN, P.O. BOX 222, HERMANN, MO
MFA - JEFFERSON CITY, P.O. BOX 105757, JEFFERSON CITY, MO
MFA - MARSHALL, ROUTE 5, MARSHALL, MO
MFA - OTTERVILLE, P.O. BOX 207, OTTERVILLE, MO
MFA - OWENSVILLE, P.O. BOX 120, OWENSVILLE, MO
MFA - PILOT GROVE, 9326 MILE CORNER RD., PILOT GROVE, MO
MFA - SALISBURY, P.O. BOX 161, SALISBURY, MO
MFA - TIPTON, P.O. BOX 399, TIPTON, MO
MFA - VANDALIA, 814 W. WASHINGTON, VANDALIA, MO
MID STATE SERVICES, 9942 Schrand Lane, Williamsburg, MO
MISSOURI GAS ENERGY, 3420 BROADWAY ATTN:ENERGY ASSISTANCE, KANSAS CITY, MO
MITCHELL KERBY, 16551 S. PALIS NICHOLS RD., HARTSBURG, MO
MT. STERLING OIL COMPANY, P.O. BOX 37, MT. STERLING, MO
NILGES HTG. & COOLING, P.O. BOX 1187, Linn, MO
OLIVER JONES, 4977 ST. RD. PP, NEW BLOOMFIELD, MO
PALMER DALE, 3802 MINT JULEP, COLUMBIA, MO
PAM DAVIS, BOONVILLE, MO
RALLS COUNTY ELECTRIC CO-OP, P.O. BOX 157, NEW LONDON, MO
RUDROFF PROPERTIES, P.O. BOX 1159, Linn, MO
SCOTT GAS, INC., P.O. BOX 346, ELDON, MO
SELBY HEATING & AC, INC., P.O. BOX 7626, COLUMBIA, MO
SERVICE & SUPPLY COOPERATIVE, P.O. BOX 48, BELLFLOWER, MO
SNELL PROPANE GAS COMPANY, P.O. BOX 101, CENTRALIA, MO
SO-CAL GAS, INC., P.O. BOX 104988, MOKANE, MO
THOMAS J. PAYNE, 1711 W. WORLEY, COLUMBIA, MO
THREE RIVERS ELECTRIC, P.O. BOX 918, LINN, MO
THREE RIVERS PROPANE, P.O. BOX 1104, LINN, MO
TYREE PARTS & HARDWARE, Columbia, MO
WALMART, P.O. BOX 530933, ATLANTA, GA
WESTLAKES, P.O. BOX 219370, KANSAS CITY, MO
WHITNEY APPLIANCE & REPAIR, 1145 Highway J, Chamois, MO
WOOD, GENERAL DELIVERY, MO
WRIGHT PROPANE, 302 E. US HWY 24, SALISBURY, MO
EA Vendor Numbers, name and city (Enough to identify specific vendors - not mailing address.)
                                                                                      Delete the three
Non-Participating Vendor - 00000-0-000                                               bogus examples.
Cylinder Propane - 22222-2-222                                                      Enter your list, and
Kerosene - 66666-6-666                                                                    then sort
Landlord Situation - 77777-7-777                                                     alphabetacally to
Wood - 88888-8-888                                                                 speed searching by
Renter Situation- 99999-9-999                                                               users.
Avoricious Natural Gas - 015-355-000                                               To sort you need to
Pricey Propane Central City - 45678922-000                                         unprotect the sheet.
Sample Vendor - Sometown 55555555-001                                              Go to "Tools" on the
                                                                                     menu bar, choose
                                                                                     "Protection," then
                                                                                     "Unprotect." The
                                                                                     password for this
                                                                                    sheet is simply the
                                                                                      number 1. After
                                                                                  sorting, re-protect the
                                                                                  same way. You don't
                                                                                  want people changing
                                                                                              it.
                                                                                  To sort, highlight the
                                                                                   list you want to sort.
                                                                                     Go to Data on the
                                                                                       menu bar, and
                                                                                  choose "Sort." In the
                                                                                    box that comes up,
                                                                                   "Ascending" means
                                                                                    starting with A and
                                                                                        going up the
                                                                                          alphabet.
ng address.)
      Delete the three
     bogus examples.
    Enter your list, and
          then sort
     alphabetacally to
   speed searching by
            users.
   To sort you need to
   unprotect the sheet.
   Go to "Tools" on the
     menu bar, choose
     "Protection," then
     "Unprotect." The
     password for this
    sheet is simply the
      number 1. After
  sorting, re-protect the
  same way. You don't
  want people changing
              it.
  To sort, highlight the
   list you want to sort.
     Go to Data on the
       menu bar, and
  choose "Sort." In the
    box that comes up,
   "Ascending" means
    starting with A and
        going up the
          alphabet.
                         MISSOURI DEPARTMENT OF SOCIAL SERVICES
                         FAMILY SUPPORT DIVISION                                              County                                        Date Application Stamped
                         LIHEAP ELIGIBILITY WORKSHEET FFY09

HEAD OF HOUSEHOLD NAME                                                                        HEAD OF HOUSEHOLD SOCIAL SECURITY NUMBER


CATEGORY A INCOME: (EA/FS HOUSEHOLD MATCH; ATTACH FAMIS SCREENS)

  Gross Earned Income:                                               Gross Earned Income: =                                                 DEDUCTIONS
                                                                                              $           -
                                                                                                                               Is HOH or Spouse 65+,
                                                                              EI Deduction    X .80
                                                                                                                               or disabled?
                                                                                                                               X = Yes                       $    -
  Gross Unearned Income: +                                                    Net Earned: = $             -                    Child Support
                                                                                                                               Deduction:            --
  Total Gross Income:          =                                Gross Unearned Income: +
                                                                                                                               SMI deduction:           --
                                   $        -                                                 $           -
                                                                               Subtotal: =                                                  $       -
                                                                                              $           -                 Total Net Income: = $                 -
                                                                                                                                            Zero
  CATEGORY B INCOME:                                                                              CATEGORY B TOTALS
HOUSEHOLD MEMBER                                HOUSEHOLD MEMBER
                                                                                                              RESOURCES - Amounts from Application

  EARNED INCOME                                 EARNED INCOME
     Check Date              Gross Amount           Check Date             Gross Amount
1                                               1

2                                               2

3                                               3

4                                               4                                                 $                                 -              TOTAL RESOURCES

5                                               5                                                                           HOUSEHOLD INCOME
                         TOTAL GROSS                                  TOTAL GROSS                 GROSS INCOME CALCULATION:
 $                 -     EARNED INCOME          $               -     EARNED INCOME
                                                                                                  GROSS EARNED:
               X .80 (EI DEDUCTION)                         X .80 (EI DEDUCTION)                                                             $                    -
                                                                                                  GROSS UNEARNED
                           NET EARNED INCOME                            NET EARNED INCOME                                                    $                    -
     $               -                               $           -                                GROSS SELF EMPL.:                     +
HOUSEHOLD MEMBER                                HOUSEHOLD MEMBER                                                                             $                    -
                                                                                                  TOTAL GROSS INCOME  = $                                         -
 UNEARNED INCOME                                UNEARNED INCOME                                   NET INCOME CALCULATION:
    Check Date  Gross Amount                        Check Date             Gross Amount
1                                               1                                                             Net Earned        $                                 -
2                                               2                                                         +   Net Unearned      $                                 -
3                                               3                                                         +   Net Monthy F/B    $                                 -
4                                               4                                                         = SUBTOTAL            $                                -
5                                               5                                                  Is HOH or Spouse                         DEDUCTIONS
              TOTAL GROSS                                               TOTAL GROSS                 65+, or disabled?
 $         -  UNEARNED INCOME      $          -                         UNEARNED INCOME               X = Yes                   $                                 -
 SELF-EMPLOYMENT INCOME: (MUST USE TAX FORM 1040)
  HOUSEHOLD MEMBER                                                                                        Child Support
                                                                                                           Deduction --

                                                                                                      SMI Deduction --
STEP 1:                  FARM/BUS. INCOME                        GROSS MONTHLY INCOME
                                                    DIV. 12 =    $                     -                      $         -      Zero
                                                                                                                                Total NET Income
STEP 2:              GROSS MONTHLY INCOME                        NET MONTHLY INCOME
                     $                  -           X .80 =      $                     -              =           $                                                   -
                                                    (EI DED)

MO 886-0632 (9-07)                                                                                                                                               EA-1A (9-07)
HEAD OF HOUSEHOLD NAME                                                                          HEAD OF HOUSEHOLD SOCIAL SECURITY NUMBER
   0                                                                                                                       000-00-0000
    CHECK PURPOSE OF FORM:                  EA:                       WINTER ECIP:                                       SUMMER ECIP:
SUPPLIER INFORMATION:

 EA VENDOR ID # =                                                                                            HEAT CODE =


  PRIM. SUPPLIER NAME, ADDRESS:

     2NDARY SUPPLIER (NOT for EA):

(Type vend. & Address if not on list.):

                     PRIMARY HEAT SOURCE:                                                 SECONDARY HEAT SOURCE:
                                                                                                Primary Supplier                        Secondary Supplier
   SERVICE THREATENED                       CUSTOMER ACCOUNT NUMBER:
   Primary           Secondary                  DATE SUPPLIER CONTACTED:

                                                        PERSON CONTACTED:
                                                                                                    Yes             No                Yes              No
    SERVICE TERMINATED                                  PAYMENT ACCEPTED:

   Primary           Secondary                                   ALTERNATE SUPPLIER:

                                                                 CITY:


RENTER INFORMATION:                     HEAT CODE:

                                                                                                                            (NOT TO EXCEED MAX. PER FUEL TYPE)
                                         X 12 =     $             -             X .08 =         $               -
                MONTHLY RENT                         ANNUAL RENT                  0              EST. BENEFIT




                                                                AGENCY AUTHORIZATION
                                  HOH/SPOUSE Disabled:                      Other Member Disabled:                                60 or Older:
  # In House                              Yes              No                             Yes                       No                           Yes        No
A Member is 5 or Younger:         A Member is 3 to 5 yrs old:                   A Member is 2 or younger:                        Fuel Pmts.
             Yes         No               Yes              No                             Yes                       No           Oth. Assist.

                                                                                                                         (Determining LIHEAP eligibility after EA

           X         APPROVE             ESTIMATED EA BENEFIT AMOUNT                                N/A                  program has closed.)

                         OBLIGATED
                                                  To Primary Fuel Vendor                                    To Secondary Fuel Vendor
                        ECIP AMOUNT:



                      DENY



 IF DENIAL IS T-OTHER, EXPLAIN:
Payment Amounts From other funding sources
   Source 1                                 Amount 1                        Acct./Vcher #.                                     Fuel Type
   Source 2                                 Amount 2                        Acct./Vcher #.                                     Fuel Type
   Source 3                                 Amount 3                        Acct./Vcher #.                                     Fuel Type
EA WORKER/INTERVIEWER SIGNATURE                                          DATE                             REVIEWER/SUPERVISOR SIGNATURE


                                                                                  11/14/10
MO 886-0632 (9-07)                                                                                                                                           EA-1A (9-07)
                           LIHEAP PLEDGE LETTER
     From:
0
0
0


January 0, 1900

To: 0

On the above date our agency has agreed to pay your company, up to the pledged
amount on behalf of the customer as indicated below.

Fuel type              0

Customer:              0
Address:                                                               ERROR - No Address Ente
Account #              0

Pledged Amounts & Sources:
                  EA: (Pd. By State of Mo.)     $                  -
                  ECIP: (Pd. By Agency)         $                  -




                             TOTAL PLEDGE:      $                 -




Authorized Signature
                           LIHEAP PLEDGE LETTER
     From:
0
0
0


January 0, 1900

To: 0

On the above date our agency has agreed to pay your company, up to the pledged
amount on behalf of the customer as indicated below.

Fuel type              0

Customer:              0
Address:                                                               ERROR - No Address Ente
Account #              0

Pledged Amounts & Sources:
                  ECIP: (Pd. By Agency)         $                  -




                             TOTAL PLEDGE:      $                 -




Authorized Signature

				
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