FDF
2016_2017_LIHEAP_APPLICATION_PACKET6_CLEAR_02_James.pdf
Department of Community Services and Development
LIWP Energy Intake Form
CSD 43L (4/21/2017)
* indicates a required field
APPLICANT INFORMATION
First Name *
Middle Initial
Last Name *
Mailing Address *
Unit Number
Mailing City *
Mailing County *
Mailing Zip Code *
SERVICE ADDRESS
Address where applicant lives (this
cannot
be a P.O. Box)
Is your service address the same as mailing address? *
...............................................................................................................
Yes
No
Have you lived at this residence during each of the past 12 months *
…………………………………………………………………………………….
Yes
No
Service Address *
Unit Number
Service City *
Service County *
Service Zip Code *
Telephone Number *
Message:
E-mail Address:
Categorical Eligibility
Do you or anyone in your household receive assistance from one of the following programs?
(see below)
:
Bureau of Indian Affairs General Assistance
Medi-Cal
ESAP (Energy Savings Assistance Program)
NSLP (National School Lunch Program)
Tribal Head Start
WIC (Women, Infants and Children
Low-Income Home Energy Assistance Program (LIHEAP)
Medi-Cal for Families
SNAP (Federal Supplemental Nutritional Assistance Program) CALFRESH
SSI (Supplemental Security Income)
TANF (Temporary Assistance for Needy Families) CALWORKS
Tribal TANF
HOUSEHOLD MEMBERS:
AMOUNT OF MONTHLY GROSS INCOME:
gross
income means the amount of money received before taxes
on a separate piece of paper.
First Name
Last Name
Relation to Applicant
Date of Birth
MM/DD/YY
Source of Income
Amount of
Monthly Income
*
$
$
$
$
$
$
$
$
Household Total Monthly Gross Income
$
Disabled
Native American
Seasonal Migrant Wor
ker
or anything else is taken out. If you have more than 8 people in your household, you can write the information
$
$
$
$
$
$
$
$
$
$
$
$
$
$
* * * *
ELECTRIC
SERVICE
Is your electricity shut-off? *
Yes
No
Do you have a past due
OR
shut-off notice? *
Yes
No
NATURAL GAS SERVICE
Is your Natural Gas shut-off? *
Yes
No
Do you have a past due
OR
shut-off notice? *
Yes
No
Are the utility bills in your name ONLY? *
Yes
No
Are your utilities included in rent or submetered? *
Yes
No
If your utility bill is in someone else’s name, enter that name here:
____________________________________________________
ELIGIBILITY VERIFICATION AND CONSENT TO SHARE INFORMATION
The information on this application will be used to determine
and verify my eligibility for assistance and to provide me with energy efficiency services. 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 declare, under penalty of perjury, that the information on this application is true, correct.
X
* *
SIGNATURE of Applicant
* *
Today’s Date
Witness
’s
Signature (
If signed with an X
)
X
* *
SIGNATURE of Electric Utility Customer of Record, (if different)
* *
Today
’s
Date
* *
SIGNATURE of Gas Utility Customer of Record, if different
* *
Utility Company Information
Electric Service
Company Name: * _____________________________
Account Number: * ____________________________
Natural Gas Service
Company Name: * _____________________________
Account Number: * ____________________________
Utility Service Address ID: * _____________________
_____________________
Utility Service Address ID: * _____________________
_____________________
Total Monthly Energy Costs: $ *
_______________
Total Monthly Energy Costs: $ *
_______________
* *