LIHEAP Utility Assistance Application Form – 2021

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.

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).

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.