Welcome to the Home Energy Assistance Program Application Guide, presented by San Joaquin County Human Services Agency, Aging and Community Services.

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The purpose of this document is to provide information on:

1. How to successfully complete and submit an application for HEAP or Free Weatherization

2. Tips on managing your energy bill and saving money3. Programs to help lower your household’s monthly expenses

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To get started, the Home Energy Assistance Program, also known as HEAP:

Assists with a once-per-year payment of your applicants electric, gas, wood or propane utility bill. The program provides help with either propane, firewood or energy bill (Pacific Gas & Electric, City of Lodi Electric Utility or Modesto Irrigation District)

To qualify for assistance:

• Must reside in San Joaquin County• Be a US Citizen or legal resident• Have income that does not exceed the income limits • Be responsible for energy costs in the home

HEAP assistance will not impact any Public Assistance Programs you are participating in.

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Assists renters and homeowners by installing free energy saving measures through minor home repairs to single-family homes, multi-unit dwellings, and mobile homes.

Must complete the HEAP application and be HEAP eligibleComplete the Weatherization Intake FormRenters must obtain landlord/owner consentDwelling cannot be for sale or in foreclosure

The Weatherization Program provides free energy upgrades and home repairs to eligible households and dwellings.

Some of the upgrades available include:• Refrigerators• Microwaves• Washers• Dryers• Ceiling Fans• Weather-stripping• Insulation• and more.

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We will now cover how to apply for energy assistance.

The application packet contains all the forms required to apply for assistance with HEAP and Weatherization. In addition to the required forms, supporting documents must be submitted with the application.

To successfully process a HEAP request the application must include:

Acknowledgment Form (CE-CSD 321)

Energy Intake Form (CSD 43)

Include Proof of Income for every household member

Statement of Citizenship or Non-Citizen Status

Account Holder Authorization and Consent Form

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The next step is to gather the documents to include with your completed application:1. Include all pages of your most recent energy bill/statement from all utilities

(electric, gas, and/or propane). Also include the past due notice if your services are shut-off or at risk of shut-off.

2. Include proof of income for all household members. Paycheck stubs must be concurrent with no gaps in between. Please refer to the document checklist for a list of income types.

1. Adults 18 years of age or older living in the household that have no income must complete a Form 43B Certification of Income and Expenses.

2. Households with Zero Income must complete an additional form LIHEAP Statement of Financial Support and also include a rental agreement or mortgage statement, proof of last payment, and a recent bank statement.

3. Include your birth certificate or current US Passport for proof of citizenship. For permanent residents photocopy of permanent resident card (or ‘green card’) copies of both sides.

4. Utility and income documents must be current for the last 30 days or no older than 6 weeks.

5. Please submit copies. Do not send originals, copies only, as documents will not

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be returned.

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We will now cover the forms themselves. We are starting with:The Acknowledgment FormThis form explains the total gross income limits based on the number of household members. It also provides a list of items needed for submission. 1. Request to attach all copies of utility bill.

2. Copies of current income of entire household.

3. Proof of Citizenship status

4. Reminder to complete Weatherization referral form.

5. Acknowledgment applicant will receive Energy Conservation information.

6. Reminder that application can be delayed if not complete.

7. Application must have applicants name, signature and be dated.

Forms can be located online: http://www.sjchsa.org/About-Us/Forms

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The Weatherization Intake Form

Households approved for HEAP may also qualify for weatherization services. The dwelling may qualify for repair or replacement of a refrigerator, stove, washing machine, dryer, freezer, water heater, or microwave; insulation; minor home repair, LED light bulbs; smoke and carbon monoxide detectors; shade screens; weather-stripping; and much more.

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The Energy Intake FormThis form requires the most time and detail. Carefully read each question.

We will review the separate sections now.The form is broken into several sections. The top section on page one is the applicant’s information, including name, address, utility service information and social security number. A phone number is requested as this assists the application processor if there are issues with the application.

The middle of page one asks for specific information regarding the household members and income. This assists in determining the applicant’s household eligibility. See the Documentation Checklist for details on proof of income.

The bottom box of page one is to list all members of the household, if there are more than 7 members a separate piece of paper should be used to record that information. At bottom section of the last box, if anyone in the household receives CalFresh, the box should be marked “yes” and a “Passport to Services” printout should be included with application.

Do not send originals, copies only, as documents will not be returned.

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Page two of the Energy Intake Form requests specific information regarding the service bill including if the applicant has had services shut-off or received a past due notice.

This is important as it could shift the priority process for the application.

All pages, front and back, of the most recent bill or statement from the service provider must be provided. A 15-Day or 48-Hour notice is not a monthly statement, although the 15-Day or 48-Hour notice should be included if you have received one.

WPO - This section is specifically for applicants that utilize Wood, Propane or Fuel Oil; if they do not apply “n/a” should be indicated.

The middle section of page two contains specific information regarding the energy sources used at the service location and must be completed.

Lastly the form must be signed and dated on page two. Forms missing information cannot be processed and the applicant will be notified of missing information which could delay receipt of potential services.

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The Statement of Citizenship or Non-Citizenship Status for Public Benefits – Form CSD 600Citizens and Nationals of the United States and Non-Citizens who meet all eligibility, may qualify to receive services from HEAP and Weatherization.Examples of acceptable types of proof are:• US birth certificate, • Copies of Passport,• Permanent Resident Card; OR• CA REAL ID card. *Note that the California REAL ID noted “Limited Term” under the bear is not acceptable as proof of citizenship or permanent residency. Please note that copies of both sides of a Permanent Resident Card need to be attached to application. Both sides of form must be completed. Do not send originals, copies only, as documents will not be returned.

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The Account Holder Authorization and Consent Form

If the applicant is not the account holder for the energy service provider (your name is not on the energy statement or bill for the residence) an Account Holder Authorization and Consent Form should be completed and signed by the account holder authorizing SJC Aging and Community Services and your service provider permission to communicate regarding the details on the account.

If the applicant is also the account holder this form does not need to be completed.

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The “How did you hear about the HEAP program” form

This is a form used by Aging and Community Services to determine effective outreach methods of reaching applicants.

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The PG&E CARE/FERA Program ApplicationThese are PG&E discount programs that help eligible customers pay their energy bills. Over 1.4 million customers are receiving a bill discount through these two programs. Simply complete the online CARE/FERA enrollment form or the form attached to the application and the applicant will be notified if eligible.

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Please submit both the regular bill / statement and the 48-hour or 15-day notice with the application if you have received one.ALL pages of your statement need to be submitted.

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The OIG (Office of Inspector General) Hotline Operations accepts tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement in the U.S. Department of Health and Human Services’ programs. Every report received is important; however, not every submission results in an investigation. Due to the high volume of complaints OIG receives, it is not possible to contact every complainant. However, Hotline tips are incredibly valuable, and OIG appreciates your efforts to help stamp out fraud, waste, and abuse.

Your Rights under the Low Income Home Energy Assistance Program (LIHEAP) are outlined on this document.

The Documentation Checklist goes into detail about what documents can be used for the application, please use this important resources as you complete your forms.

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The next step is to gather the documents to include with the completed application:1. All pages of the most recent energy bill from all utilities (electric, gas, and/or

propane). Including past due notice if services are shut-off or at risk of shut-off.2. Proof of income for all household members. Paycheck stubs must be concurrent

with no gaps in between. Please refer to the document checklist for a list of income types.

1. Adults 18 years of age or older living in the household that have no income must complete a Form 43B Certification of Income and Expenses.

2. Households with Zero Income must complete an additional form LIHEAP Statement of Financial Support also include a rental agreement or mortgage statement, proof of last payment, and a recent bank statement.

3. Include a copy of the birth certificate or current US Passport for proof of citizenship.

4. Permanent residents will need to include a copy of the permanent resident card (or ‘green card’), both sides of card.

5. Utility and income documents must be current for the last 30 days or no older than 6 weeks.

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Adults 18 years of age or older living in the household that have no income must complete a Form 43B Certification of Income and Expenses.

Households with Zero Income must complete an additional form LIHEAP Statement of Financial Support and also include a copy of the rental agreement or mortgage statement, proof of last rent or mortgage payment, and a recent bank statement.

1. Proof of income for all household members. Paycheck stubs must be concurrent with no gaps in between. Please refer to the document checklist for a list of income types.

1. Adults 18 years of age or older living in the household that have no income must complete a Form 43B Certification of Income and Expenses.

2. Households with Zero Income must complete an additional form LIHEAP Statement of Financial Support and also include a rental agreement or mortgage statement, proof of last payment, and a recent bank statement.

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Complete application packet and income certification forms can be downloaded from the HSA website.Individual forms or supporting documentation forms such as the CSD-43B may also be downloaded from this HSA website.

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Applications and supporting documents may be submitted several ways:

• US Mail to the Energy Program Office. • A postage paid envelope is included with each application packet if the

application was mailed to you.• Energy Program | PO Box 201056 | Stockton, CA 95201

• Drop box in the South Lobby of the Human Services Agency• 333 E. Washington Street | Stockton, CA 95202

• Fax : 209-932-2649

• E-Mail: heap@sjgov.org

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Once an application is received by the HEAP office, processing takes 4 to 6 weeks.

Complete applications will be reviewed, processed and approved for benefit, and applicant will receive a benefit letter by mail. The HEAP credit will appear on the applicants bill in 1 to 2 billing cycles after approval.

Incomplete applications will be reviewed and applicant will receive a letter indicating what documents are needed to complete the process. Incomplete applications will be delayed in processing and applicants should continue to make payment arrangements to avoid disconnection. If you receive a notice to turn in missing documents please do so immediately, as delays can cause expiration of the documents you have already provided.

Applications with 48-hour or shut-off notices will be forwarded to the Crisis Unit for immediate assistance. In all circumstances, you should please continue to pay or make arrangements to pay the utility bill to avoid delinquency or disconnection.

If you are unable to obtain assistance through the HEAP program, please seek assistance through other resources, including:• The REACH Program - for a one-time payment of a utility bill offered through the

Dollar Energy Fund.

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• https://www.dollarenergy.org/need-help/california/reach-program/• The California Public Utilities Commission - for assistance in advocating for services

to be restored or for payment arrangements on a past due account.

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Be aware of how you use your energy and conserve. Information is available online on our “Forms” page.

Contact your service providers to find out about any consumer programs they may have available for you to participate in.

We have information online on how to make a home budget. Located on our “Forms” page is a fillable “Make a Budget” form that can give you an idea of where your money is spent. Having a home budget can make all the difference in managing household expenses.

http://www.sjchsa.org/About-Us/Forms

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There are a number of energy discounts and tools to help you save and manage energy costs. Be involved in your energy bill.By calling 1-877-660-6789 a PG&E customer service representative can help you: • Review your energy usage and help you to compare rate plans to find the best

plan for you.• Enroll in CARE to save 20% on your energy costs per month.• Apply for Medical Baseline Allowance :

• The Medical Baseline Program, also known as Medical Baseline Allowance, is an assistance program for residential customers who have special energy needs due to qualifying medical conditions. The program includes two different kinds of help:

• 1. A lower rate on your monthly energy bill• 2. Extra notifications in advance of a Public Safety Power Shutoff

• Sign up for Bill Forecast Alerts to allow you to set a limit on the amount you want to pay per month, and receive a text or phone message when your energy cost is about to exceed that amount so that you may adjust your energy usage.

• Enroll in Budget Billing: With Budget Billing, a free program from PG&E, you can average out your energy costs for more manageable monthly payments. Using your energy use history, PG&E will level out your monthly payment amount, so if your energy usage changes significantly from season to season, you won’t see big spikes on your bills. PG&E will average your annual energy costs over the last

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12 months to determine a monthly payment amount, then adjust your monthly amount once every 4 months if your actual energy usage has significantly changed. This amount may go up or down.

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If you have additional questions on how to complete your HEAP application, please call 209-468-1500.

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