Notice ID: 9141498205

DEPARTMENT OF HUMAN SERVICES

27 EAST 7TH STREET
BLOOMSBURG, PA 17815

Mail Date: 12/04/2024 OFFICE OF INCOME MAINTENANCE

Glen Whitenight Record ID: 19/0088727 Telephone: 1-570-387-4200

1127 Scotch Valley Dr Notice ID: 9141498205 MCI #: 630185366
Bloomsburg, PA 17815
COMPASS: The fast and easy way to apply for benefits
www.compass.state.pa.us

Pennsylvania receives information from other state and federal agencies to verify the information you
give them. If you misrepresent, hide, or withhold facts which may affect your eligibility for benefits, you
may be required to repay your benefits, and you may be prosecuted and disqualified from receiving
certain future benefits.

Dear Mr. Whitenight,

You've applied for or are receiving the following benefits and we need more information:

Health Care (MA/CHIP)

LIHEAP Cash
SNAP

In order to finish processing your request, please complete the following next steps:

1. Return copies of the documents listed below and this form to the Department of Human
Services by December 16, 2024. Please see the "Additional Instructions" section.

Please provide proof of the following information for your case. You must cooperate in
providing and signing the required documents or your benefits may be denied, delayed, or
closed. If you are cooperating in the completion of your application or reapplication, we will
help you provide proof, as needed. The information below will explain what is needed and who
it is needed for.

Provide the following Needed for: *Provide the following Additional Information
documents: documents:

Income

Zero Income Statement WHITENIGHT, Form HSEA 6 and proof of If you receive financial help
GLEN income, if any. from family provide a letter
from family member.

If you have a disability and need this letter in large print or another format, please
call our helpline at 1-800-692-7462. TDD Services are available at 1-800-451-5886.

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 Notice ID: 9141498205

Income

Zero Income Statement WHITENIGHT, Form HSEA 6 and proof of Have the letter contain an
GLEN income, if any. amount ,contact info and if
this is a loan or gift

Additional Information

Primary Heating Source WHITENIGHT, Copy of heating bill or letter Please set up an account
GLEN from your heating provider with Fruit's fuel and write
stating that you are a down the acct #
customer. You must verify
your primary source of heat.

*If you do not have the documents listed above, please refer to the last sheet in this packet for
examples of other documents that you can provide. If you are having trouble getting these
documents please contact us at 1-877-211-1322.

To mail the documents and other forms:

1. Place your copied documents and this form in the envelope included in this packet and
mail it to the Department of Human Services.
2. Please put your case number 19/0088727 or your Social Security Number on each page
of the documents you are sending.
3. If you do not return the documents listed above, your request cannot be processed and
you may not receive benefits.

To fax the documents and other forms:

1. Please put your case number 19/0088727 or your Social Security Number on each page
of the documents you are faxing.
2. Fax your documents to 570-387-4708 .
3. If you do not return the documents listed above, your request cannot be processed and
you may not receive benefits.

To submit items through the COMPASS website:

1. Go to www.compass.state.pa.us.
2. Log in to your My COMPASS Account; or create an account if you do not have one.
3. To submit documents with your application: Select your application and click 'Scan
Documents' or 'Attach A File'.
4. To submit documents to your case record: Make sure your case is linked to your
account, go to Report Changes and click 'Scan Documents' or 'Attach A File'.
To upload documents using the myCOMPASS PA mobile app:
1.Download the myCOMPASS PA mobile app.
2. Log in to your My COMPASS Account; or create an account if you do not have one.
3. To upload documents with your application: Select your application, go to Documents,
and click 'Upload Docs'.
4. To upload documents to your case record: Select your case record, go to Documents,
and click 'Upload Docs'.

To drop your copied items off at your local County Assistance Office (CAO):
1. Please put your case number 19/0088727 or your Social Security Number on each page
of the documents you are dropping off.
2. The address of your local CAO is provided on this document at the top of the first page.

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 Notice ID: 9141498205
If you do not have the documents listed on the first page, use the following list to find a
different type of document:
Provide Provide a copy of the following documents (note you only need
Proof Of: to provide proof of a document if it is listed on the first page):
For Identification select one of the documents below:
Driver's License
Passport
Selective Service Card
ID Card issued by Federal, State or local government with individual's picture

For Income select one of the documents below:

Earned Income Pay stubs Pay envelope
Employer's statements IRS form 4070 (form used to report tips)
Current check stubs or Tax returns or business records for
photocopies self employment
Income producing contract

Unearned Court Order

Income Benefit payment check

IRS form 1099 (form used for interest)

Income Tax Statement

For Expenses select one of the documents below:

Rent or Statement from institution holding the mortgage
Mortgage Mortgage or rent receipt
Statement by the landlord or manager

Utilities Current statements or receipts from the utility company

Statement from the landlord
Lease showing that the household pays for heating and/or cooling costs
separate from the rent
Medical Statements from providers
Expenses
Health insurance policies
Statements or bills from physicians, pharmacists, or other certified providers
For Resources select one of the documents below:
Bank books Real estate tax receipt
Bond/stock certificates Financial institution statements
Contract Bank Statement
Mortgage Receipt of deposit
Sales Agreement Will
Income Tax Return Securities
For Citizenship select one of the documents below:
U.S. Passport
Certificate of Naturalization
Certificate of U.S. Citizenship
Report of birth abroad of a citizen from the U.S.

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 Notice ID: 9141498205

For PA Residency select one of the documents below:

Rent Receipt Church Record
Receipt for Mortgage/Utility Statement from someone who
Payment knows you
Deed Tax Office Record
Lease Agreement Collateral Contact
For Student Status select one of the documents below:
Award Letter
Statement from organization providing loan, grant, scholarship
Statement from school's financial aid office

Receipts from the book store

For Disability select one of the documents below:
Supplemental Security Income
Social Security Disability
Statement from licensed Physician, Physician’s Assistant, Certified
Registered Nurse Practitioner, or Psychologist identifying the medical
disability, the duration of the disability, any employability limitations, and any
need for health-sustaining medications, if applicable.
For Criminal History select one of the documents below:
From local magistrate's office, court official or law enforcement agency
From another county/state, court official or law enforcement officer
From parole or probation officer
From other official sources
For Job Search select one of the documents below:
Completed Job Application Report
Registration and applications made via with JobGateway
Detailed personal log, including employer, date, and result of application
Note: TANF cash applicants need to verify in writing that they have applied
for at least three jobs per week while their application is being processed.
This will be calculated by the CAO on an average basis. For example, if an
applicant verified in writing that they applied for a total of nine jobs over a
three week period that would be acceptable.

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 Notice ID: 9141498205
CAO NAME AND ADDRESS CASE IDENTIFICATION
CO RECORD NUMBER CSLD DIST.
DEPARTMENT OF HUMAN SERVICES
27 EAST 7TH STREET 19 0088727 0
BLOOMSBURG, PA 17815 RECORD NAME DATE

570-387-4200 Glen Whitenight 12/04/2024

ZERO INCOME STATEMENT

This form must be completed and signed by the applicant whose household has little or no income.

Has your household received any income in the month before you applied for LIHEAP?
YES NO

If yes, please tell us where it came from and how much you received:

Please tell us how your household is meeting its needs for the following items:

Food:

Shelter:

Utility service (electricity, heat, water, etc.):

Print Name

Signature Date

HSEA 6 9/16

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 Notice ID: 9141498205

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