LIHEAP Utility Assistance Application 2021 Step 1 of 5 20% Name* First Middle Last Date of Birth* MM slash DD slash YYYY SERVICE ADDRESS*Address where you live (this cannot be a P.O. Box) Service Address Unit Number Service City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Service State Service City Zip Code Have you lived at this residence during each of the past 12 months?* Yes No Is your service address the same as mailing address?* Yes No Mailing Address* Mailing Address Unit Number Mailing City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Mailing State Mailing Zip Social Security Number* (SSN)Email Telephone Number*PEOPLE LIVING IN HOUSEHOLD*Enter the total number of people living in the household, including yourself Demographics* Enter the number of people in the household who areAges 0 – 2 YearsAges 3 ‐ 5 yearsAges 6 ‐ 18 yearsAges 19 ‐ 59Ages 60 and olderDisabledNative AmericanSeasonal or Migrant FarmworkerINCOME*Enter the total number of people who receive income Gross monthly Income ($)*Enter the total gross monthly income for all people living in the household:TANF / CalWorksSSI / SSPSSA / SSDIPaycheck(s)InterestPensionOtherTotal Monthly Income*Upload Proof of Income* Drop files here or Select files Accepted file types: jpg, pdf, png, Max. file size: 8 MB. Must be within the past 30 days. If applicable, must include proof of CalFRESH and/or other cash assistance (current Passport to Services or Notice of Action).HOUSEHOLD MEMBERS*ENTER THE INFORMATION BELOW FOR ALL HOUSEHOLD MEMBERS. First NameLast NameRelation to Applicant (for yourself, write "Self")Date of Birth (MM/DD/YY)Amount of Gross Income (Before Taxes and Deductions)Source of Income Household Total Monthly Gross Income*Are you or someone in your household CURRENTLY receiving CalFresh (Food Stamps)?* Yes No PAY BILLTo which energy bill (CHOOSE ONLY ONE) do you want the LIHEAP benefit to be applied?* Natural Gas Electricity Wood Propane Fuel Oil Kerosene Other Fuel Enter the energy company and account number:*Company NameAccount #:Is your utility service shut-off?* Yes No Do you have a past due notice?* Yes No Are your utilities included in rent or submetered?* Yes No Are your utilities all electric?* Yes No Is your Natural Gas Company the same as your Electric Company?* Yes No WOOD, PROPANE or FUEL OIL SERVICE (WPO)*Are you currently out of fuel? (Wood, Propane, Oil, Kerosene, Other Fuels) Yes No N/A List the approximate number of days until you run out of fuel (Wood, Propane, Oil, Kerosene, Other Fuels)*Number of Days ENERGY INFORMATIONThe questions below are MANDATORY. Please check all energy sources used to heat your home. A copy of all recent energy bills and/or receipts for any home energy cost must be provided. NOTE: A copy of an electric bill must be included even if you do not use electricity to heat your home.What is the main fuel used to HEAT your home?*One main heating source MUST be checked. Natural Gas Electricity Wood Propane Fuel Oil Kerosene Other Fuel N/A In addition to your main heating source, do you ever use any of the following to heat your home (you can select more than one):* Natural Gas Electricity Wood Propane Fuel Oil Kerosene Other Fuel N/A Are you the account holder:*Electric Bill Yes No Natural Gas BillNatural Gas Bill Yes No Upload Bills*A copy of all recent energy bills and/or receipts for any home energy cost must be provided. It MUST be the WHOLE bill so that we can see your energy cost AND usage (usually a table showing how much energy you used). NOTE: A copy of an electric bill must be included even if you do not use electricity to heat your home. Drop files here or Select files Max. file size: 8 MB. Consent*The information on this application will be used to determine and verify my eligibility for assistance. By signing below, I give my consent (permission) to CSD, its contractors, consultants, other federal or state agencies (CSD Partners) and to my utility company and its contractors, to share information about my household’s utility account, energy usage and/or other information needed to provide services and benefits to me as described at the end of the form. My consent shall be effective for the period beginning 24 months prior to, and continuing for 36 months after, the date signed below. I understand that if my application for LIHEAP/DOE benefits or services is denied, or if I receive untimely response or unsatisfactory performance, I may initiate a written appeal with the local service provider and my appeal shall be reviewed no later than 15 days after the appeal is received. If I am not satisfied with the local service provider's decision I may then appeal to the Department of Community Services and Development pursuant to Title 22, California Code of Regulations section 100805. If applicable, I hereby authorize installation of weatherization measures to my residence at no cost to me. I declare, under penalty of perjury, that the information on this application is true, correct, and that the funds received will be used solely for the purpose of paying my energy costs. I agreeName* First Last Date* MM slash DD slash YYYY AGENCY NAME: Community Services and Development (CSD). UNIT RESPONSIBLE FOR MAINTENANCE: Home Energy Assistance Program (HEAP). AUTHORITY: Government Code Section 16367.6 (a) Names CSD as the agency responsible for managing HEAP. PURPOSE: The information you provide will be used to decide if you are eligible for a LIHEAP payment and/or weatherization services. GIVING INFORMATION: This program is voluntary. If you choose to apply for assistance, you must give all required information. OTHER INFORMATION: CSD uses statistical definitions from the annual update of the Department of Health and Human Services' State Median Income, Federal Income Poverty Guidelines, to determine program eligibility. During application processing, CSD's designated subcontractor may need to ask you for more information to decide your eligibility for either or both programs. ACCESS: CSD's designated subcontractor will keep your completed application and other information, if used, to determine your eligibility. You have the right to access all records holding information about you. CSD does not discriminate in the provision of services on the basis of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, age, or sexual orientation. THIS PART OF THE FORM MUST BE COMPLETE IN ORDER FOR PROCESSINGHome Energy Assistance ProgramCSBG Intake Form 2021Household Member Information*Name of Household Member (First, Last)Sex (M/F)Date of Birth (MM/DD/YY)Relationship to Applicant (if you are the applicant, write "Applicant")AgeRace/EthnicityEducation (Last Grade Completed)Health Insurance (Yes or No) Household Demographics* Single Person Single Parent: Female Single Parent: Male Two Adults - No Children Two Parent Are you an IMACA employee?* Yes No Did your home receive Home Energy Assistance in 2020?* Yes No If yes, check the box you received assistance with: Wood Propane Oil/Kerosene Electric Weatherization Do you own or rent a home?* Own Rent Consent*The information on this application will be used to determine and verify my eligibility for assistance with any IMACA program. I also understand that IMACA does not discriminate in the provision of services on the basis of race, color, national origin, disability, age, sex or sexual orientation. I certify that the information I have given is correct and is not provided with the intent to defraud. I am aware that any deliberate falsification of information will be grounds for immediate dismissal/denial from any IMACA program. I hereby acknowledge that the information relating to the determination of my eligibility requires verification and/or documentation, and that by my signature I authorize all parties, whether they be third party agencies or individuals, to release any and all such information. I certify under penalty of perjury, that all information herein is true, correct and to the best of my knowledge. I certify that I have received Energy Education: Information regarding changes you can make in order to reduce the energy consumption of your household (available on our LIHEAP website page). I agreeName* First Last Date* MM slash DD slash YYYY CSD 43B (rev.12/2013)CERTIFICATION OF INCOME AND EXPENSESPlease complete this section of the form ONLY if an adult 18 years and older CANNOT provide proof of income. The State of California requires the applicant to report all sources of income. This form will help us understand how you are meeting expenses. Please complete the information below:Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Do you have sources of income you forgot to report?During the previous month have you been employed part time? Yes No During the previous month have you been self-employed? Yes No During the previous month did you receive money for any work that you perform only once in a while, like yard work, child care, donating blood, etc? Yes No During the previous month have you received any gifts of money from anyone? Yes No If yes, please list the name and phone number of the person who gave you the gift:NamePhone Number During the previous month did you receive any of the following: (check any that apply) WORKER’S COMP UNEMPLOYMENT GOVERNMENT SPONSORED BENEFITS CHILD SUPPORT Do you receive any of the following (check any that apply) ANNUITY PENSION TRIBAL CASINO PAYMENTS RENTAL INCOME INSURANCE BENEFITS Are you spending your savings or borrowing money to cover monthly expenses?Are you using savings or a home equity loan? Yes No How much? Are you using some other asset? Yes No How Much? Are you borrowing from credit cards? Yes No How much? Are you borrowing from some other source? Yes No How much? Please tell us how you paid these monthly expenses during the previous months:Rent or MortgageMONTHLY COSTHOW HAS THE EXPENSE BEEN PAID?DOES SOMEONE ELSE PAY YOUR RENT OR MORTGAGE FOR YOU? Yes No Their Name Their Phone Number Their Address Utility BillsMONTHLY COSTHOW HAS THE EXPENSE BEEN PAID?DOES SOMEONE ELSE PAY YOUR UTILITY BILL FOR YOU? Yes No Their Name Their Phone Number Their Address FoodMONTHLY COSTHOW HAS THE EXPENSE BEEN PAID?DOES SOMEONE ELSE PAY FOR FOOD FOR YOU? Yes No Their Name Their Phone Number Their Address Section 4:If none of the above applies to you, please explain how your monthly expenses were paid: ConsentBy signing this form, I affirm that I believe these facts are accurate and true. I give the Service Provider my permission to verify this information. I may be held liable under federal or state law for knowingly making false or fraudulent statements. I agreeName First Last Date MM slash DD slash YYYY Account Holder Authorization and Consent Form CSD Form 081 (Rev. 12/17)ACCOUNT HOLDER NAME(S) AND MAILING ADDRESSAccount Holder’s Full Name* First Middle Last Account Holder’s mailing address* Street Address Unit Number City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is the utility service address the same as the account holder’s mailing address?* Yes No Full Name of Applicant for Benefits (from Form 43)* First Last Utility Service Address (Street)* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code UTILITY INFORMATION*Please enter your utility company name and service account number below (you can find the account number on your bill). If different companies provide your electricity and gas services, please enter the name and account number for both utilities.Name of Utility CompanyService Account NumberName of Utility Company (if you have a second Utility Company)Service Account NumberAUTHORIZATION AND CONSENT*By signing this form, you (Account Holder) give your authorization and consent (permission) to CSD, its contractors, consultants, other federal or state agencies (CSD Partners) and to your utility company and its contractors, to share information about your property’s utility account, meter usage and energy consumption data, and other information as needed for the period beginning 24 months prior to, and continuing for 36 months after, the date signed below. The information you authorize us to obtain and share will be used for the purposes of evaluating home energy usage of program beneficiaries so that CSD can: a) measure the effectiveness of the services we provide by determining how much your utility bills are reduced and how much our services reduce carbon emissions (air pollution), and b) report these results to federal and state authorities that fund and oversee energy assistance programs in California. CSD, its contractors, consultants, other federal or state agencies and affiliated programs (CSD Partners), working cooperatively with your utility company and its contractors, use this information to provide services that assist low-income families, such the applicant, to pay their home energy bills and mange those energy needs for the purposes stated in this Authorization. I agreeName of Account Holder* First Last Date* MM slash DD slash YYYY Name of CSD Contractor/Partner Organization You agree that your consent shall remain in effect for 36 months from the date you sign this Authorization, unless otherwise revoked by written notice mailed to: CSD Energy & Environmental Services Division, 2389 Gateway Oaks Drive, Suite 100, Sacramento, CA 95833. Revocation will be effective upon receipt, but will not apply to any information shared while this Authorization was valid.APPLICABLE PROGRAMSSome of the programs CSD oversees or partners with include: - CSD Federal Low-Income Home Energy Assistance Program (LIHEAP) - CSD Federal Department of Energy Weatherization Assistance Program (DOE WAP) - State Low-Income Weatherization Program (LIWP) - Department of Housing and Urban Development (HUD) Lead Hazard Control and Healthy Homes Program - Utility Company Energy Savings Assistance (ESA) Program - Utility Company California Alternate Rates for Energy (CARE) Program
