The following documents are required to submit a complete Energy Assistance application. Documents may need to be re-submitted or may require supporting documentation.
1. Copy of signed, dated and completed Household Information Form.
2. Copy of income documentation for all adult household members, from all sources of income, received during previous three (3) months, including Household Income Information Form. Income received during previous 12 months may also be used.
3. Copy of residence documentation, such as a driver’s license, utility bill, lease agreement, bank statement, etc. Documentation must show primary applicant’s name and address.
4. Signed Energy and Money Savings Tips Form.
5. (Required for LIHEAP only) Copy of citizenship status documentation, such as a social security card, U.S. birth certificate or government-issued residency documents for all household members 1 year or older. Households with eligible children and no eligible adult household members are still qualified to apply. Verifying documentation is required if a household member has a social security number.
6. (Required for PSE HELP only) Copy of valid photo ID for primary applicant, such as a driver’s license, government-issued identification card or passport.
In the table below, look for the month in which you sign the application.
Please provide the gross income received by all household members for the three months before that.
| January | October, November, December | July | April, May, June |
| February | November, December, January | August | May, June, July |
| March | December, January, February | September | June, July, August |
| April | January, February, March | October | July, August, September |
| May | February, March, April | November | August, September, October |
| June | March, April, May | December | September, October, November |
Provide the following documents for each income type for all adult household members:
- No income: Each person in the home who is over 18 years old must fill out their own Declaration Statement of No Income if they did not receive any money or were not paid by their employer in any or all of the three previous months. You must be complete a separate form for each adult in the home.
- Benefits or assistance (SSI, SSA, SSDI, ABD, GA, TANF, Veterans, retirement and pension): Provide the current year’s benefit letter or an itemized bank statement showing the deposit in the month prior. To print a Social Security letter, log on at ssa.gov/myaccount/.
- Unemployment: Provide a printout of weekly gross payments from Employment Security or all weekly paystubs with dates for the previous four months. Go to esd.wa.gov. Or, make an appointment at your local WorkSource location to request a printout.
- Self-employment income: Complete a “Self-Declaration of Income” form. Provide bank statements or ledgers to prove gross income and itemized receipts for deductible business expenses. Call us at 206-812-4940 for further directions and required documents.
- Cash, personal checks, reoccurring payments from family or other income not listed: Complete a “Self-Declaration of Income” form and include bank statements or receipts as income documentation.
- Rental income: Provide a current lease agreement or proof of payments received (check or bank statement).
- Child support: Provide a DSHS printout of monthly or weekly payments or a signed statement from payer.
- COPES caregiving income: Go to your online Individual ProviderOne portal to obtain payment information.
- Earned income (only the following are accepted):
- All paystubs (usually received two to four times a month) that show gross income (before taxes) with a pay date that falls in the previous three months. Do not include paystubs with pay dates in the month the application is signed.
- Signed statement from the employer with gross wages, including all tips, commission, bonuses, etc.
- Completed and signed “Employer Earned Income Form” authorizing the employer to release information to Byrd Barr Place.
Return Your Application
When your application is complete, you may drop it off between 9 and 4, Monday through Friday, or mail it to:
Byrd Barr Place
ATTN: Energy Assistance
722 18th Ave
Seattle, WA 98122
Need Help?
If you or a household member needs one of the forms listed or you are not sure what documents to provide, email us at energyassistance@byrdbarr.place or call us at 206-812-4940. We can mail or email documents to you.
