HEAP Application Check List Please use this check off list to ensure you have all necessary documents.

□ HEAP Application Cover Sheet

□ CSD 43 Form: Heap Intake Application - 2 pages Application must be filled out completely

□ Household Members Information Form Include everyone currently living in your home including yourself

□ 1st Bill (electric or gas): Utility bill you want assistance on Must be your most current bill / include past bills too

□ 2nd Bill (electric or gas): Secondary utility bill (if applicable) Must include both utility bills / indicate which bill you would like assistance with

□ Copies of all household members income: dated within the past 30 days Must include a full months income for everyone in the household

□ Declaration of Income Affidavit Write a self affidavit for every adult (18+yrs) in the household claiming zero or cash paid income

*declarations for persons claiming zero income must include your name, address, contact number, the date and reason you have zero income *declarations for persons claiming cash paid income must include your name, address, contact number, the date, indicate the amount earned for the past 30 days and the type of work that is being done

□ Adults claiming zero income or cash paid income must include an EDD print out as proof of no income

□ Current rental agreement

□ HEAP Benefit Form - 2 copies Complete both forms

□ Client/Customer Consent Form and Authorization Form Must be completed by the person that appears on your utility bills/this name may be different then the applicant

□ Low-Cost/No Cost Energy Practices Survey: Complete the survey, sign and date

□ Every household is different - other documents maybe required in order to complete the application process

Thank you for going through the check off list. Please submit your application packet as soon as possible.

HEAP APPLICATION COVER SHEET 2017/2018

Dear Applicant,

The Home Energy Assistance Program (HEAP) would like to offer you utility assistance. For your convenience we have attached an application for utility and/or Weatherization services. Eligibility is based on the household’s total monthly gross income, which cannot exceed the LIHEAP income guidelines. We require proof of income for every adult (18 years and older) living in the household and all children in the home receiving SSI/Social Security benefits, etc. All adults receiving weekly income must submit four (4) consecutive pay stubs. All adults paid bi-weekly/bi-monthly must submit two (2) consecutive pay stubs.

All applications MUST include the following documents/information for processing: • Current electric bill (original) • Current gas bill (original)

Note: We require both utility bills in order to process your Heap application. • Copies of all household income: Dated within the past 30 days • Adults 18 years and older claiming zero income or undocumented income MUST

complete an Affidavit/Declaration and Survey of Income and Expenses Form. Note: Please include all income related receipts, stubs,letters etc. for the past 30 days in support of your

Affidavit/Declaration and Survey Form.

• Adults claiming zero income and/or undocumented income MUST also provide a current EDD print out documenting their income status.

• Applicant MUST provide a current lease or rental agreement. • Applicant MUST provide a copy of their California ID or CDL for verification

• Applicant MUST provide a copy of their Social Security Card for verification

• Applicant’s Social Security number and Date of Birth Must be filled out on the application. • Other documents may be requested by the processing staff or management • Applicant MUST sign and date the entire HEAP application packet. • The HEAP Application packet is numbered Page’s 1 – 5. • Each page MUST be filled out completely and signed by the applicant. • IF ANY PAGE IS BLANK, MISSING OR INCOMPLETE, THE APPLICATION WILL NOT

BE PROCESSED AND THE APPLICATION PACKET WILL BE RETURNED TO YOU.

The processing of your HEAP application can take 90 to 120 days from the date your completed application is received in our office. Eligible households can be assisted with one energy bill per program year. If your household has already received assistance for this current program year, unfortunately we will be unable to process your application and your application will be voided. And Denial letter will be mailed to you.

If you have any questions or concerns please contact our call center at: 888-351-4061 Once you have completed your HEAP Application, please mail it in to:

LBCAP/ELEAT Department 117 Victoria St.

Long Beach, CA 90805

Mail: Please make sure to put the correct postage on your return envelope. We are not responsible for mail that is not deliverable due to insufficient postage

MAILING ADDRESS ONLY WE DO NOT ACCEPT

WALK-INS

INTERNET APPLICATION

Page 1 of 2

First name Middle Initial Last Name Date of Birth MM/DD/YY

SERVICE ADDRESS – Address where you live (this cannot be a P.O. Box) Service Address Unit Number

Service City Service County LOS ANGELES

Service State CA

Service 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 Unit Number

Mailing City Mailing County LOS ANGELES

Mailing State CA

Mailing Zip Code

Social Security Number (SSN): Telephone Number ( )

E-mail Address:

HOUSEHOLD MEMBERS ENTER THE INFORMATION BELOW FOR ALL HOUSEHOLD MEMBERS. If you have more than 7 people in your household, please list the information on a separate piece of paper.

First Name Last Name Relation to Applicant

Date of Birth MM/DD/YY

Amount of Gross Monthly Income (Before Taxes and Deductions)

Source of Income

Self

Household Total Monthly Gross Income $

Department of Community Services and Development Official Use Only: Energy Intake Form Priority Points CSD 43 (10/2017) A.C.C. Agency: LBCAP/ELEAT Intake Initials: Intake Date: Eligibility Cert Date

PEOPLE LIVING IN HOUSEHOLD Enter the total number of people living in the household, including yourself

INCOME Enter the total number of people who receive income

Demographics: Enter the number of people in the household who are:

Enter the total gross monthly income for all people living in the household:

Ages 0 – 2 Years TANF / CalWorks $

Ages 3 - 5 years SSI / SSP $

Ages 6 - 18 years SSA / SSDI $

Ages 19 - 59 Paycheck(s) $

Ages 60 and older Interest $

Disabled Pension $

Native American Other $

Seasonal or Migrant Farmworker Total Monthly Income $

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Page 2 of 2

Are you or someone in your household CURRENTLY receiving CalFresh (Food Stamps)? ☐ Yes ☐ No

PAY BILL To which energy bill (CHOOSE ONLY ONE) do you want the LIHEAP benefit to be applied? (Attach complete copy of most recent bill or receipt) ☐ Natural Gas ☐ Electricity ☐ Wood ☐ Propane ☐ Fuel Oil ☐ Kerosene ☐ Other Fuel

Enter the energy company and account number:

Company Name: ___________________________________________ Account #: _______________________________________

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: ___________ ☐ N/A

ENERGY INFORMATION The 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 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 Bill ☐ Yes ☐ No

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.

X

* * * APPLICANT’S SIGNATURE * * * Date

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.

APPLICANT: DO NOT FILL OUT THE INFORMATION BELOW. THIS SECTION IS FOR OFFICIAL USE ONLY.

Utility Assistance being provided under which program ☐ HEAP ☐ Fast Track ☐ HEAP WPO ☐ ECIP WPO Base Benefit $_______________ Supplement $_______________ Total Benefit $_______________ Total Energy Cost $________________________ Energy Burden _________________________

Energy Services Restored after disconnection: ☐ Yes ☐ No Disconnection of Energy Services prevented: ☐ Yes ☐ No

Home Referred for WX: ☐ Home Already Weatherized: ☐

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HEAP Utility Assistance

Household Members Information Form

PLEASE PRINT NEATLY

HH First Name Age

123456789101112131415

African American Hispanic/Latino/Spanish Hawaiian/Pacific IslanderCaucasian American Indian Multi RaceAsian Alaskan Native Other

Applicant's Signature Date

Household Members:List every members information that currently lives in your household (HH) including yourself. If there is no other household members please write NONE under your name

Last Name Relation to Applicant Source of Income

SELF

Please mark applicants Ethnicity:

"Type of Income" MUST include household members monthly income for all adults & children(s).

By signing below, I certify under penalty of perjury that under the law of the State of California that the above information is true and correct.

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HEAP/FAST TRACK BENEFIT RECEIPT FORM

CUSTOMER NAME: ___________________________________ DATE: _______/________/________

WE ASSIST WITH ONE UTILITY BILL PER PROGRAM YEAR FOR OFFICE USE ONLY

----------------------------------------------------------------------------------------------------------------------- Customer please read: HEAP credits cover the electric or gas portion of the bill ONLY. HEAP does not cover any other charges that may be included on your bill. You are responsible for ALL non-electric and non-gas charges. It is still YOUR responsibility to continue to pay on your utility bill and/or make payment arrangements with the utility company until your credit has been applied to your account.

Your utility company may tell you that arrangements are not needed, please understand that if you do not make payment arrangements for yourself, your services could be in jeopardy of being disconnected, and the Heap pledge will be canceled.

HEAP credits will take up to 90 – 120 days (3-4 months) for processing.

If the bill you have submitted is a past due/disconnection notice, we may contact the utility company as a courtesy to you and make a pledge in the amount shown above. If your utility services are currently off, we will contact the utility company on your behalf to make a pledge in the amount shown above. Pledges are ONLY made when an application is complete and eligible for assistance. Please note, not all utility companies accept HEAP pledges. And not all pledges guarantees that the services will be restored. (some charges may not be covered under Heap)

Note: Your benefit is an estimated amount and may change without notice. I acknowledge that I have received Energy Education Information.

I have read and understand my responsibilities as listed above. CUSTOMER SIGNATURE:__________________________________ DATE:_______/________/________

FOR OFFICE USE ONLY DATE COPY GIVEN TO CUSTOMER:________________ DATE MAILED COPY TO CUSTOMER:________________ PROGRAM YEAR: 2017 2018 STAFF NAME:_________________________

Which utility bill do you want assistance on:

SCE LADWP AZUSA GAS LBGAS INCLUDED IN RENT (PLEASE CIRCLE ONE UTILITY COMPANY)

BASIC BENEFIT AMOUNT: $________________

SUPPLIMENTAL BENEFIT AMOUNT: $________________

TOTAL BENEFIT AMOUNT: $_________________

(TOTAL BENEFIT AMOUNT IS THE AMOUNT YOU WILL RECEIVE)

Pg. 5 of 5 INTERNET APPLICATION

HEAP/FAST TRACK BENEFIT RECEIPT FORM

CUSTOMER NAME: ___________________________________ DATE: _______/________/________

WE ASSIST WITH ONE UTILITY BILL PER PROGRAM YEAR FOR OFFICE USE ONLY

----------------------------------------------------------------------------------------------------------------------- Customer please read: HEAP credits cover the electric or gas portion of the bill ONLY. HEAP does not cover any other charges that may be included on your bill. You are responsible for ALL non-electric and non-gas charges. It is still YOUR responsibility to continue to pay on your utility bill and/or make payment arrangements with the utility company until your credit has been applied to your account.

Your utility company may tell you that arrangements are not needed, please understand that if you do not make payment arrangements for yourself, your services could be in jeopardy of being disconnected, and the Heap pledge will be canceled.

HEAP credits will take up to 90 – 120 days (3-4 months) for processing.

If the bill you have submitted is a past due/disconnection notice, we may contact the utility company as a courtesy to you and make a pledge in the amount shown above. If your utility services are currently off, we will contact the utility company on your behalf to make a pledge in the amount shown above. Pledges are ONLY made when an application is complete and eligible for assistance. Please note, not all utility companies accept HEAP pledges. And not all pledges guarantees that the services will be restored. (some charges may not be covered under Heap)

Note: Your benefit is an estimated amount and may change without notice. I acknowledge that I have received Energy Education Information.

I have read and understand my responsibilities as listed above. CUSTOMER SIGNATURE:__________________________________ DATE:_______/________/________

FOR OFFICE USE ONLY DATE COPY GIVEN TO CUSTOMER:________________ DATE MAILED COPY TO CUSTOMER:________________ PROGRAM YEAR: 2017 2018 STAFF NAME:_________________________

Which utility bill do you want assistance on:

SCE LADWP AZUSA GAS LBGAS INCLUDED IN RENT (PLEASE CIRCLE ONE UTILITY COMPANY)

BASIC BENEFIT AMOUNT: $________________

SUPPLIMENTAL BENEFIT AMOUNT: $________________

TOTAL BENEFIT AMOUNT: $_________________

(TOTAL BENEFIT AMOUNT IS THE AMOUNT YOU WILL RECEIVE)

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Page 1 of 1

Department of Community Services and Development Account Holder Authorization and Consent Form CSD Form 081 (Rev. 12/17)

ACCOUNT HOLDER NAME(S) AND MAILING ADDRESS Account Holder’s Full Name Account Holder’s mailing address (Street)

Unit Number (if any)

(City)

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)

Utility Service Address (Street) Unit Number (if any)

(City)

State

CA 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 Company

Service Account Number

Name of Utility Company (if you have a second Utility Company)

Service Account Number

AUTHORIZATION 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.

REVOCATION OF AUTHORIZATION AND CONSENT 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 PROGRAMS

Some 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

Signature of Account Holder Date Name of CSD Contractor/Partner Organization

INTERNET APPLICATION

LOW-COST/NO-COST ENERGY PRACTICES SURVEY INSTRUCTIONS: Read each sentence listed below. Put an (X) in the box if it is a true statement about you or your family members.

COOLING: To keep my home cool in Summer:

□ I use an electric fan.

□ I use an evaporative cooler.

□ I use a window-mounted air conditioner set at MEDIUM

or LOW only.

□ I use a window-mounted air conditioner set at HIGH.

□ I use central air conditioning with the thermostat set at

78 degrees or higher.

□ I use central air conditioning with the thermostat set

lower than 78 degrees.

HEATING: To keep my home warm in Winter:

□ I heat my house both night and day because it costs

more to heat a cold house.

□ I try to heat only one or two rooms at a time.

□ I keep my heater clean and filters changed.

□ I heat my home with my kitchen stove or oven.

□ I open all the drapes every morning when I get up.

□ I wear sweaters during the winter and keep the

thermostat no higher than 68 degrees.

□ I use an electric blanket at night and turn off all other

heat.

APPLIANCES:

□ I have more than one refrigerator/freezer in my home.

□ I have a manual defrost style freezer and defrost it

every three months.

□ I have a freezer that automatically defrosts itself.

□ I have one TV and it is Black and White.

□ I have one or more COLOR TVs and the picture comes

on instantly.

□ I use an electric clothes dryer in my home.

HOT WATER USE:

□ I take tub baths.

□ I take showers that last no longer than 5 minutes.

□ My family members take showers that last

longer than 5 minutes.

□ I use only COLD WATER to wash clothes.

□ I use WARM water to wash clothes.

□ I use HOT water to wash clothes.

□ I always wash the dishes by hand.

□ I use a dishwasher with the DRYING CYCLE turned

OFF

□ I use a dishwasher and let the machine dry the dishes.

□ I have a leaky HOT water faucet.

LIGHTS:

□ I turn off the lights when I leave a room.

□ My family members DON'T turn off the lights when they

leave a room.

□ I use fluorescent light bulbs instead of incandescent

bulbs.

□ I HAVE BEEN INFORMED OF AND/OR AGREE TO LBCAP WEATHERIZATION PROGRAM

STATEMENT: I have been provided with a thorough explanation and written description of the Energy Efficient Weatherization Measures Guide, the Family

Budgeting Guide, and have participated in completing the Energy Efficient Practices Survey.

______________________________________________ ______________________________ _________________

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