KATHY HOCHUL
Governor
DANIEL W. TIETZ
Commissioner
BARBARA C. GUINN
Executive Deputy Commissioner
February 10, 2023
Dear New York State Water and/or Sewer Supplier:
This is to provide you with information regarding the 2022-2023 New York State (NYS) Low Income
Household Water Assistance Program (LIHWAP). Please review all enclosed materials carefully.
NYS LIHWAP began a new Federal Fiscal Year (FFY) on October 1, 2022 and updated the NYS LIHWAP
application. Our office is aware that many vendors send or supply copies of the LIHWAP application
to customers to facilitate their ability to apply and we want to make sure that you have the most
current version of this form. The updated version of the NYS LIHWAP application – OTDA-5196 (Rev.
11/22) is attached to this letter for your convenience when supplying or sending to your customers.
The Office of Temporary and Disability Assistance (OTDA) has set up a secure Application Portal for
households to apply for LIHWAP online. Personally Identifiable Information (PII) is requested as
part of the LIHWAP application process and OTDA wants to ensure this information is secure and
protected. If an applicant is unable to access the LIHWAP Application Portal, OTDA encourages them
to mail or fax a paper application and the necessary documentation. OTDA does not suggest
submitting applications or sending documentation to the New York State (NYS) LIHWAP email address
as NYS OTDA does not recognize email as a secure method to transmit and receive applications or
documentation. NYS OTDA will not be held liable for loss of PII if sent by the applicant or vendor
to any NYS LIHWAP email
address. NYS OTDA suggests that vendors send any PII through the NYS LIHWAP fax number, 518-
486-1259 or by mail to:
NYS LIHWAP PO Box 1789
Albany, NY 12201
We look forward to working with your company and staff as we assist LIHWAP eligible households in
meeting their water and/or sewer needs during FFY 2022-2023.
If you have any questions, please contact the OTDA LIHWAP Bureau at NYSLIHWAP.vendor@otda.ny.gov
or 1-518-473-1277.
Sincerely,
Keri Stark
Keri Stark
LIHWAP Bureau Chief
Employment and Income Support Programs
Attachments:
LIHWAP Application for Benefits-OTDA-5196 (Rev. 11/22)
OTDA-5196 (Rev. 11/22)
New York State Office of Temporary and Disability Assistance
Low Income Household Water Assistance Program (LIHWAP) Application for Benefits
Send completed and signed application to: NYS OTDA/LIHWAP, PO Box 1789, Albany, NY, 12201
Applicant or Household Information (please print)
The person who has primary and direct responsibility for payment of the water and/or sewer bill
should complete this application. The bill should be
in this person’s name.
First Name: Last
Name:
MI: Street Address:
City: State:
Zip:
Telephone Number:
Landline Mobile County of Residence:
Mailing address if different than above:
Email Address (optional):
Other Names by which I have been known are:
Housing Type: Own Rent with water and/or sewer in rental fee
Rent with water and/or sewer billed separately Other
Combined Water & Sewer Water
Has your service been shut off: Yes No Do you have a shut off
notice: Yes No
I am applying for help with: a past due bill. a current bill.
Vendor Name:
Account Number:
Service period (if listed on the bill) From: To:
Amount owed: $
Sewer
Has your service been shut off: Yes No Do you have a shut off
notice: Yes No
I am applying for help with: a past due bill. a current bill.
Vendor Name:
Account Number:
Service period (if listed on the bill) From: To:
Amount owed: $
List all members of your household, including yourself. Attach additional sheets as needed. Gender
Identity, Ethnicity, and Race are optional. To identify race, please use the following: American
Indian or Alaska Native (I), Asian (A), Black or African American (B), Multi- race (M), Native
Hawaiian or Other Pacific Islander (P), White (W), Other (O).
1. First Name: Last Name:
MI:
Date of Birth
Sex: Male Female Gender Identity (Optional)
Relationship to applicant Self
Social Security Number
Citizen/ US National or Qualified Alien: Yes No
Ethnicity Hispanic, Latino or Spanish Origin (Optional): Yes No Race
(Optional) _
2. First Name: Last Name:
MI
Date of Birth
Sex: Male Female Gender Identity (Optional)
Relationship to applicant
Social Security Number
Citizen/ US National or Qualified Alien: Yes No
Ethnicity Hispanic, Latino or Spanish Origin (Optional): Yes No Race
(Optional)
3. First Name: Last Name:
MI:
Date of Birth
Sex: Male Female Gender Identity (Optional)
Relationship to applicant
Social Security Number
Citizen/ US National or Qualified Alien: Yes No
Ethnicity Hispanic, Latino or Spanish Origin (Optional): Yes No Race
(Optional) _
4. First Name: Last Name:
MI:
Date of Birth
Sex: Male Female Gender Identity (Optional)
Relationship to applicant
Social Security Number
Citizen/ US National or Qualified Alien: Yes No
Ethnicity Hispanic, Latino or Spanish Origin (Optional): Yes No Race
(Optional) _
OTDA-5196 (Rev. 11/22)
New York State Office of Temporary and Disability Assistance
Is anyone in the household receiving any of the following benefits? Home Energy Assistance
Program (HEAP), Supplemental Nutrition
Assistance Program (SNAP), Temporary Assistance (TA), or Supplemental Security Income
(SSI Living alone)
If yes, who is receiving?
_Case number(s):
Is anyone in the household disabled or blind? Yes No If yes,
who?
Income: Provide income information for all members of the household, including yourself, for the
previous month. Applicant must provide proof of income. Applicant may attest to income information
on behalf of other household members. Source of income is the Employer Name, Social Security,
Social Security Disability, Child Support, Rental Income, etc. Frequency is how often you are paid:
Weekly, Monthly, Bi-weekly, etc. Gross amount is amount paid before deductions. If receiving
Medicare, please enter gross amount and indicate amounts paid for Part B and/or D.
Name of who receives Source of Income
Frequency Gross Amount Medicare Part B and/or D
$ $
$ $
$ $
$ $
Important Information and Consents: (Please read carefully before signing)
I understand that by submitting this application all information is true, complete and correct. I
understand that any false statements or other misrepresentation knowingly made by me in connection
with this application for Low Income Household Water Assistance Program (LIHWAP) benefits may
result in my being found ineligible for the assistance paid on my behalf to my water and/or sewer
provider (vendor). Additionally, any false statement or misrepresentation knowingly made by me for
purposes of obtaining assistance under this program may result in an action against me which may
subject me to civil and/or criminal penalties. Information provided on this application or
discovered through verification may be disclosed to other state, federal, and local agencies for
official examination and to law enforcement officials for the purpose of investigating or
prosecuting fraud. If a claim arises against my household, the information on this application,
including all SSNs, may be referred to federal and state agencies, as well as private claims
collection agencies, for claims collection action.
I understand that by signing this application, I consent to any investigation by any means
available to the New York State Office of Temporary and Disability Assistance (OTDA) to verify or
confirm the information I have given in connection with my application for LIHWAP benefits. The
information I have provided on my LIHWAP application and documents I have provided, will be used to
check identity and may be disclosed or re-disclosed to verify earned and unearned income and other
assistance received for myself and other household members, and to determine if applicants can
receive payments or other help. I give my consent for OTDA or other state, federal, local, or
other authorized personnel to record, store, access, and utilize the information provided on this
application and any documents that I have provided, as well as information provided in any
conversations, texts, or other means of communication with OTDA or other state, federal, local, or
other authorized personnel. I expressly consent to the release of information provided on this
application or pertaining to my eligibility for LIHWAP to any entity necessary for LIHWAP
administration including, but not limited to, social services districts, other local agencies or
entities, and the U.S. Department of Health and Human Services (HHS). I also consent to the release
and use of information provided on this application or pertaining to my eligibility for LIHWAP to
any other entity to avoid duplication of benefits. I understand that additional information may be
requested by OTDA in connection to my application for LIHWAP benefits, and I agree to provide such
requested information within the time allotted by OTDA.
I understand and agree that by providing a phone number or cellular phone number on this
application or requesting to be contacted through text messages (SMS/MMS), that OTDA may use that
number to call, send text messages, or leave voice messages related to LIHWAP. Standard text
messaging and data rates from the wireless carrier may apply. Any costs related to receiving calls
or text message are the responsibility of the individual receiving them. NYS and its agents are not
responsible for and will not accept or assume any liability for damages, losses, claims, expenses,
or costs including, but not limited to, voice, text, and data costs that may result from, or be
related to, your application for LIHWAP. Check with your phone service provider for details on
receiving calls or text messages
(SMS/MMS). Text messages or calls may be sent or made using an automatic telephone dialing system.
I understand and agree that by providing an e-mail address correspondence concerning LIHWAP may be
sent by OTDA to the e-mail address I provided.
I also consent to allow the information provided on this application to be used in referrals to
available water and/or sewer assistance programs, weatherization programs, and my utility company’s
low income programs. I understand that OTDA will use my Social Security Number to verify with my
water and/or sewer vendors the receipt of LIHWAP. This authorization also includes permission for
any of my vendors (including my utility) to release certain statistical information, including but
not limited to, my water and/or sewer usage, consumption, annual cost, and payment history to OTDA,
and HHS for the purposes of LIHWAP performance measurement.
I have read and understand the consents above and agree to the authorizations and consents therein.
I understand and agree that by signing and submitting this application to OTDA that I do so under
penalty of perjury, and I am affirming the information contained herein is true, complete and
correct.
Name (print)
Signature
Date:
Authorized Representative: You can designate someone who knows your household circumstances to be
your authorized representative. Your Authorized Representative may: complete and file your LIHWAP
application, contact the agency and speak with your worker, have access to eligibility information
in your case file, complete all forms for you, provide documentation, and appeal agency decisions.
You must still sign this application. The Authorized Representative designation will remain in
effect unless revoked by you. I would like to designate and authorized representative.
Yes No
Name (print)
Signature
Date:
OTDA-5196 (Rev. 11/22)
New York State Office of Temporary and Disability Assistancetructions for Applicants
Send completed and signed application to: NYS OTDA/LIHWAP
PO Box 1789
Albany, NY 12201
What will I need to apply? Applicants must include the following documentation/information along
with this application. Please provide copies and not originals:
• Proof of identity for the primary applicant. Identity documentation is requested for all other
household members, but not required.
• Proof of residence. You must be residing at the residence for which you are requesting
assistance.
• A water and/or sewer bill listing your permanent and primary residence. The bill should be in
the person’s name who is filling out the
application.
• Documentation of income for the primary applicant. The amount of the income for all other
household members must be entered, but documentation is not required.
• A valid Social Security Number (SSN) for the primary applicant. SSNs are requested for all
other household members, but not required.
Who should complete and sign the application? The application should be completed by the person who
has primary and direct responsibility for payment of the water and/or sewer bill.
What address should I list? You must list your current address. This must be your permanent and
primary residence.
Why do you need my telephone number? This will assist in timely processing of your application if
additional information is required.
Who should I list as household members? List everyone who lives in your house, even if they are not
related to you or contributing financially to your household. List yourself first on line 1.
Gender Identity: New York State ensures your right to access State benefits and/or services
regardless of sex, gender identity or expression. You must report your sex and the sex of all
household members as male or female. The sex you report here must be the same as what is currently
on file with the United States Social Security Administration. The sex you report is needed to
process your application. It will not appear on any benefit card you may receive or any other
public-facing document. Gender identity is how you perceive yourself and what you call yourself.
Your gender
identity can be the same as or different from your sex assigned at birth. Gender identity is not
required for this application. If your gender identity, or the gender identity of anyone in your
household, is different than the sex you proport for that person and you would like to provide that
person’s gender identity, print “Male”, “Female”, “Non-Binary”, “X”, “Transgender”, or “Different
Identity” in the space provided. If you print “Different Identity”, you may choose to describe
that person’s gender identity further in the space provided.
Citizen/Alien Information: In order to receive LIHWAP, you must be a U.S. citizen, Qualified Alien,
or U.S. non-citizen national. For additional information on what constitutes a Qualified Alien or
U.S. non-citizen national, please contact the New York State Office of Temporary and Disability
Assistance hotline at 1-800-342-3009 or visit the OTDA website at http://www.otda.ny.gov.
Race/Ethnicity Information: Providing this information is voluntary. It will not affect the
eligibility of the persons applying or the level of benefits received. The reason for requesting
this information is to ensure that program benefits are distributed without regard to race, color,
or national origin.
Do I need to provide a Social Security number for everyone? A valid Social Security number is
required for the applicant and requested for all other household members. If any member does not
have a Social Security number but has applied for one, write the word “applied” in the Social
Security Number box. If you leave this section blank for the primary applicant household member,
your application cannot be processed but will be pended for further information.
How should I complete the income section? Will I need to provide proof? List ALL earned and
unearned income for all household members. All amounts should be entered as gross income prior to
any deductions. Deductions include, but are not limited to: income taxes, child support,
garnishments, health insurance, and union dues. You are required to submit documentation of all
earned and unearned income, including self- employment and rental income for the primary applicant.
You may be required to provide proof of other income. Do not submit originals, they will not be
returned. Eligibility will be based on your household’s gross monthly income for the month of
application. Please enter the amount of your Social Security before any deductions for Medicare.
List separately the amounts that you pay for Medicare Part B and/or D. Amounts for Medicare Parts
B and D are excluded as income. Enter only the interest or dividend portions of bank accounts, CDs,
stocks, bonds or other investment income. List each account separately. If you need more space,
attach additional sheets. Enter the amount received for the year to date.
Make sure to sign and date the application. The application must be signed by the person who has
the water and/or sewer bill in their name.
Appeals: An appeal may be requested if it has been more than thirty (30) business days since OTDA
received your signed and completed application and you have not been told of the eligibility
decision. Incomplete applications may be pended for up to ten (10) business days and the pending
period is not counted in the thirty (30) business day timeframe for providing notification.
Applicants who are denied or disagree with the amount of assistance for which they were approved
may request an appeal within 60 days from the date of the notice. Appeals may be requested by email
at NYSLIHWAP.appeals@otda.ny.gov, by telephone at (833) 690-0208, or in writing: NYS OTDA/LIHWAP,
PO Box 1789, Albany, NY, 12201.
OTDA-5196 (Rev. 11/22)
New York State Office of Temporary and Disability Assistance
Types of Acceptable Documentation
Residence (Where you now live)
• Current rent receipt with name and address of tenant and landlord or lease with name and
address
• Water, sewer, or tax bill
• Homeowner’s/Renter’s Insurance Policy
• Utility bill
• Mortgage payment books/receipts with address
Identity
You must provide one or more of the following for the primary applicant.
• Driver’s License
• Photo ID
• US Passport or Naturalization Certificate
• Birth Certificate or Baptismal Certificate*
• Validated Social Security Number*
• Statement from another person*
*Two forms of proof required.
Social Security Number
You must provide a valid Social Security Number (SSN) for the primary applicant. If you do not have
an SSN, you must apply for one at the Social
Security Administration (SSA).
Water and/or Sewer Verification
Please provide a copy of your most recent water and/or sewer bill, a current tax bill indicating
water and/or sewer charges or a statement from your vendor. If you have separate bills for water
and sewer, please provide copies of both bills.
Income:
• Pay stubs for the most recent four (4) weeks
• If self-employed, business records for the most recent three (3) months or your filed
federal tax return for the current year, including all applicable schedules.
• Rental income/expenses for previous three (3) months or your filed federal tax return for
the current year, including all applicable schedules.
• Child support or alimony/spousal support
• Interest/Bank/Dividend or Tax Statement
• Statement from roomer/boarder
Copy of award letter or official correspondence for the following:
• Social Security/Supplemental Security Income (SSI)
• Veteran’s Benefits
• Pensions
• Worker’s Compensation/Disability
• Unemployment Insurance Benefits
40 North Pearl Street, Albany, NY 12243-0001 │www.otda.ny.gov
