home energy assistance program (heap) · home energy assistance program (heap) application packet...

HOME ENERGY ASSISTANCE PROGRAM

(HEAP) APPLICATION PACKET

Helping Alameda County residents with paying their PG&E/Alameda Power bill

MAIL Completed Applications with REQUIRED DOCUMENTS to:

Spectrum Community Services HEAP Program P. O. Box 4317

Hayward, CA 94540

PLEASE DO NOT USE WHITE OUT.

To apply for HEAP, you may pick up applications at the following locations during regular business hours.

OAKLAND RESIDENTS: Downtown Oakland Senior Center 200 Grand Ave. Oakland, Ca 94610 East Oakland Senior Center 9255 Edes Ave. Oakland, Ca 94621 North Oakland Senior Center 5714 Martin Luther King Jr. Way, Oakland, Ca 94609 West Oakland Senior Center 1724 Adeline St. Oakland, Ca 94607 Oakland Community Assistance Office One Frank Ogawa Plaza, Rm 123, Oakland, CA 94612

NORTH COUNTY RESIDENTS:

Berkeley

Strawberry Creek Lodge 1320 Addison St. Berkeley, Ca 94702

South Berkeley Senior Center 2939 Ellis St. Berkeley, Ca 94703

Redwood Gardens 2951 Derby St Berkeley, Ca 94705

North Berkeley Senior Center 1901 Hearst Ave. Berkeley, Ca 94710

Emeryville Senior Center 4321 Salem St. Emeryville, Ca 94608

Albany Senior Center 846 Masonic Ave. Albany, Ca 94706

SOUTH COUNTY RESIDENTS:

Hayward, Castro Valley, San Leandro, San Lorenzo, Fremont, Union City, Newark

Fremont Multi-Service Sr. Center Hayward/Eden Area One-Stop Career Center 40086 Paseo Padre Parkway 24100 Amador St. 3rd Floor Fremont, CA 94538 Hayward, CA 94541

Ralph & Mary Ruggieri Center Fremont Family Resource Center 33997 Alvarado Niles Rd. 39155 Liberty Ste. A110

Union City, CA 94587 Fremont, CA 94538

LIVERMORE VALLEY RESIDENTS:

Dublin, Pleasanton, Livermore Livermore Senior Center 4444 East Ave. Livermore, Ca 94550 Livermore Public Library 1188 S. Livermore, CA 94550

ALAMEDA RESIDENTS: Alameda Power & Telecom 2000 Grand Ave. Alameda, Ca 94501

Mail completed applications with required documents to: Spectrum Community Services

HEAP Program P.O. Box 4317

Hayward, Ca. 94540

HEAP Eligibility Applicant Agreement

The federal HEAP (Home Energy Assistance Program) program requires states to assist qualified low-income households with low-incomes and high energy cost. The priorities for assistance are households with SENIORS, DISABLED PERSONS, and households with CHILDREN FIVE and UNDER. The chart below shows the gross income guidelines for this program:

2017 MONTHLY GROSS INCOME GUIDELINE

HOUSEHOLD SIZES MONTHLY

GROSS INCOME 1 $2,091.922 $2,735.583 $3,379.25 4 $4,022.92 5 $4,666.58 6 $5,310.25

Please remember HEAP is not an entitlement program. Spectrum also offers weatherization services to help households’ lower their utility bills. All applicants are encouraged to work out payment plans with their utility company.

I understand and have read the above.

Questions: Call (510) 881-0300, Ext: 214, 216, 225 or 226

Signature Date

P.O. Box 4317 Hayward, CA 94540 (510) 881-0300 www.SpectrumCS.org

How to fill out the

Home Energy Assistance Program (HEAP) application

SAMPLE APPLICATION

Please do not fill out this form.

1) & 2) Please fill out your First and

Last Name.

3) Please fill out your mailing address.Please include your Unit Number or

apartment number.

4) Please fill your Date of Birth.

5) Is your service address with PG&E/Alameda Power the same as your

mailing address? Yes or No?

6) Please fill in your Social SecurityNumber.

7) Please fill in your TelephoneNumber.

8) How many people are living in yourHousehold including you? Pleaseinclude the breakdown of the people’sages by category. Example: Howmany people living in your householdare between the Ages 19-59? 1,2, 3?How many people are Ages 60 andolder? 1,2 ? Please include yourself.

9) Please fill in the total number ofpeople who have INCOME in this box.

Please also include the kind of

INCOME below. Is it SSA, SSI,

Paycheck or Other type of INCOME?

10) Please fill out your First and LastName, your Date of Birth, Amountof Monthly Income, and Source ofIncome. Please include anyone livingin your household. Please fill in theHousehold Total Monthly Gross

Income (before taxes).

11) Are you or someone currently

receiving Cal/Fresh (Food Stamps).


2)

8)

4) 1)

3)

9)

7) 6)

5)

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11)

Sample

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12) Please check the appropriatebox(es) and please fill in the Com-pany Name and the Account #.

13) What is the MAIN fuel used to

heat your home? GAS or ELECTRIC

14) In addition to your main heatingsource, do you ever use any other ofthe following heat sources in yourhome (you can select more than

one).

15) Are your utilities all electric? Isyour electricity shut-off? Do you have

a past due notice?

16) Is your Natural Gas Companythe same as your electric Company?Is your electricity shut-off? Do you

have a past due notice?

17) Not applicable N/A

18) Are your utilities included in the

rent or sub metered?

19) Please sign your name and in-

clude the date.


13)

14)

12)

15) 16)

17)

18)

19)

Sample

Page

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1) Please fill in your name.

2) Please fill out your mailing address includingthe city and zip code.

3) Please check the boxes. This section showsthat you have received information aboutEnergy Education and Budget Counseling.

4) Please sign your name.

5) Please fill in the date.

Please fill this form only if you do not

have income and/or if a member of your

household is 18 years or older and does

not have income.


1)

2)

3)

4) 5)

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

Mailing Address Unit Number

Mailing City Mailing County Mailing State 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 State Service Zip Code

Social Security Number (SSN): Telephone Number ( ) ☐Message Only?

E-mail Address (Optional):

HOUSEHOLD MEMBERS (Optional) FULL NAME: Full name is First Name, Last Name. RELATIONSHIP TO THE APPLICANT: For example: husband, daughter, friend, aunt, grandfather, etc. DATE OF BIRTH: List the date of birth of each household member. AMOUNT OF MONTHLY GROSS INCOME: “gross” income means the amount of money received before taxes or anything else is taken out. If you have more than 8 people in your household, you can write the information on a separate piece of paper.

First Name Last Name Relation to Applicant

Date of Birth MM/DD/YY

Amount of Monthly Income Source of Income

Self

Household Total Monthly Gross Income $ Are you or someone in your household CURRENTLY receiving CalFresh (Food Stamps)? ☐ Yes ☐ No

Department of Community Services and Development Official Use Only: Energy Intake Form Priority Points CSD 43 (11/2015) A.C.C.Agency: Intake Initials: Intake Date: Eligibility Cert Date

Job Control Code

PEOPLE LIVING IN HOUSEHOLD Enter the total number

of people living in the household, including the applicant

INCOME

Enter the number of household members who receive income

Demographics - Enter the number of people who are: Enter 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 Income $

Spectrum CS

To which energy bill do you want the LIHEAP benefit to be applied? (Attach copy of most recent bill or receipt)

☐ Natural Gas ☐ Electricity ☐ Wood ☐ Propane ☐ Fuel Oil ☐ Kerosene ☐ Other FuelList energy company and account number: Company Name: _____________________ Account #: ____________________________What is the main fuel used to HEAT your home? A main heating source MUST be checked. (Attach copy of most recent bill or receipt)

☐ Natural Gas ☐ Electricity ☐ Wood ☐ Propane ☐ Fuel Oil ☐ Kerosene ☐ Other FuelIn addition to your main heating source, do you ever use any of the following to heat your home (you can select more than one): (Attach copy of most recent bill or receipt)

☐ Natural Gas ☐ Electricity ☐ Wood ☐ Propane ☐ Fuel Oil ☐ Kerosene ☐ Other Fuel ☐ N/AEnergy Bill Information Check all that apply for each type of energy source for any home energy costs. NOTE: The questions below are MANDATORY and require a response. Required: Attach copies of all most recent energy bills and/or receipts. A copy of an electric bill must be included.

ELECTRIC SERVICE

Are your utilities all electric? ☐ Yes ☐ No _ __ __Is your electricity shut-off?☐ Yes ☐ No Do you have a past due notice?☐ Yes ☐ No

NATURAL GAS SERVICE

Is your Natural Gas Company the same as your electric Company? ☐ Yes ☐ No Is your Natural Gas shut-off?☐ Yes ☐ No Do you have a past due notice?☐ 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

Are your utilities included in rent or submetered? ☐ Yes ☐ NoThe information on this application will be used to determine and verify my eligibility for assistance. My signature gives consent for this information to be shared with other offices of the state and federal governments, their designated subcontractors, my utility company(ies), and for my utility company(ies) to share my account information with the Department of Community Services and Development (CSD), its designated subcontractors, and other offices of the state and federal governments for the purpose of providing services to me and to coordinate, improve and reduce the costs of services under these programs. I further authorize my utility company(ies) to provide my energy consumption data to CSD to the extent necessary for CSD to comply with the program reporting requirements of the federal government. I understand that this consent shall remain in effect for three years from the date signed unless otherwise revoked by me in writing. 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 * * * Today’s Date Witness’s Signature (If signed with an X)

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 Supplement $________________ Total Benefit $_______________ ☐ Home referred for WX ☐ Home already weatherizedEnergy Services Restored after disconnection: ☐ Yes ☐ No Disconnection of Energy Services prevented: ☐ Yes ☐ No Type of Dwelling: ☐ MFD – Owner, 2 - 4 units ☐ Mobile Home – Owner ☐ Shelter: # of units _______ ☐ Unoccupied MFD: 2 – 4 units☐ SFD – Owner, 1 unit ☐ MFD – Rental, 2 - 4 units ☐ Mobile Home - Rental Total # of residents: _____ ☐ Unoccupied MFD: > 5 units ☐ SFD – Rental, 1 unit ☐ MFD – Owner, 5 or more units Total Energy Cost: Energy Burden:

☐ MFD – Rental, 5 or more units $ %Agency Defined Priorities: ☐ Medically Needy ☐ Frail Elderly ☐ Severe Financial Hardship ☐ Hard to Reach ☐ Priority Offsets ☐ N/A

Put Notary stamp below, if needed (DOE only) or have Executive Director Sign here

Department of Community Services and Development CSD 43B (rev.12/2013)

CERTIFICATION OF INCOME AND EXPENSES

You are being asked to complete this form because you requested assistance, and state that your entire household 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 and Address

Name:

Address:

Section 3: Please tell us how you paid these monthly expenses during the previous months:

EXPENSE MONTHLY COST HOW HAS THE EXPENSE BEEN PAID? IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:

Rent or Mortgage $

Name: Phone: Address:

Utility Bills $

Name: Phone: Address:

Food $ Name: Phone:Address:

Section 4: If none of the above applies to you, please explain how your monthly expenses were paid:

Signature: By 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.

Signature Date

Section 1: Do you have sources of income you forgot to report? YES NO 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? If yes, please list the name and phone number of the person who gave you the gift:

YES NO During the previous month did you receive any of the following: (circle any that apply)

WORKER’S COMP UNEMPLOYMENT GOVERNMENT SPONSORED BENEFITS CHILD SUPPORT

YES NO Do you receive any of the following (circle any that apply) ANNUITY PAYMENT PENSION TRIBAL CASINO PAYMENTS RENTAL INCOME INSURANCE BENEFITS

Section 2: Are you spending your savings or borrowing money to cover monthly expenses?

YES NO Are you using savings or a home equity loan? How much? ____________________________

YES NO Are you using some other asset? How much?____________________________

YES NO Are you borrowing from credit cards? How much?____________________________

YES NO Are you borrowing from some other source? How much?____________________________

Why a budget?A budget is a spending plan that makes you aware of where your money is going and what is important to you. This is a one month budget to give you an example of how to spend your money. Please fill out the budget infomation below.

With this in mind, we have set up an example so you can see for yourself where your money goes.

Please add your Monthly Basic Expenses, Monthly Utilities Expenses, and PG&E/Alameda Power and subtract this Total Expenses from your Monthly Net Income.

MONTHLY BUDGET

Monthly Gross Income(before taxes) $

Monthly Net Income(after taxes) $

Monthly Basic Expenses

Rent/Mortgage $

Food $

Monthly Utilities Expenses

Water $

Telephone $

Garbage $

PG&E/Alameda Power Expenses

Gas $

Electric $

TOTAL EXPENSES $

(Monthly Net Income) minus(TOTAL EXPENSES) $


Please fill out this form and submit it with your application.

Lead-Safe Energy Mold/Moisture Budget Counseling Radon

Date Time Date Time Date Time

Lead-Safe Energy Mold/Moisture Budget Counseling Radon

Date mailed

Self-Certification Option

If the information was delivered but a signature was not obtainable, you may check the appropriate box below.

I certify that I attempted to deliver the following educational information to the dwelling listed above:

Radon Education - A copy of the pamphlet, A Citizen's Guide to Radon , informing me of the potential risk of radon and how to lower the radon level in my dwelling unit.

State of CaliforniaDEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT

CSD 321 (Rev. 12/05/11)CLIENT EDUCATION CONFIRMATION OF RECEIPT

Attempted delivery dates and times

Signature (Agency Representative)

Signature (Agency Representative) Print name

Mailing Option:

Refusal to Sign — I certify that I have made a good faith effort to deliver the information to the dwelling unit listed above at the date and time indicated and that the occupant refused to sign the confirmation of receipt. I further certify that I have left a copy of the information at the unit with the occupant.Unavailable for Signature — I certify that I have made a good faith effort to deliver the information to the dwelling unit listed above and that the occupant was unavailable to sign the confirmation of receipt. I further certify that I have left a copy of the information at the unit by sliding it under the door.

I certify that I have mailed the following educational information to the dwelling listed above (attach copy of Certificate of Mailing for lead-safe education only):

Print name

Energy Education – Information regarding changes I can make in order to reduce the energy consumption of my household.

Budget Counseling - Information regarding personal financial management.

I have received the following information:

DateSignature of Recipient

Mold and Moisture Education - A copy of the pamphlet, A Brief Guide to Mold and Moisture In Your Home , informing me of how to clean up residential mold problems and how to prevent mold growth.

Confirmation of Receipt

Lead-Safe Education – A copy of the pamphlet, Renovate Right: Important Lead Hazard Information for Families, Child Care Providers, and Schools , informing me of the potential risk of the lead hazard exposure from weatherization/renovation activity to be performed in my dwelling unit.

Name of Occupant Age of Dwelling

Address of Dwelling

YOUR APPPLICATION

COMPLETE PG&E or ALAMEDA POWER BILL must be within 30 days, please include your 48-hour notice if you have one.

PROOF OF INCOME (within the last 30 days):

SSI/SSA--2017 Award letters, bank statements, Treasury deposit, copy

of SSI/SSA check

EDD--Last 4 weeks of pay stubs

GA (General Assistance)--Cal-Learn, CalWorks, Food Stamp notice

of action letter or printout with in last 30 days

Loans or Temporary--If you are receiving help from friends and relatives, (if it is monthly, we will need a signed letter with the amount

and dates.

Self-employed--We will need signed taxes (all pages) with the

Schedule C or Ledger, or Receipt book with the last 30 days.

Pensions and Annuities--We will need the Award Letter for the last 30 days or Lifetime Award Letter.

PROOF OF DISABILITY:

SSI/SSA--Award letter 2017

Physician’s statement letter

EDD letter indicating disability

DMV placard with letter stating disability

HOUSEHOLD MEMBER OVER 60:

Please submit copies of any of the following: California Driver’s license, ID card,

United States Passport, Insurance card, or Birth Certificate.

CHILDREN 5 AND UNDER:

Please submit copies of any of the following: Birth Certificate, Immunization

record, Insurance Card, or Medical Record with birth date.


Please remember to submit:

HEAP Application Checklist

____Signed the “HEAP Eligibility Application Agreement?”

____Completed the “CSD43” Application on both sides?

____Completed “Why a budget?”

____Completed the “Client Education Confirmation of Receipt?” (NOTE: Please fill out: Name of Occupant & Address of Dwelling. Check Energy Education and Budget Counseling boxes. The Energy Education is the “Energy Tips” sheet that you can keep. The Budget Counseling is the “Why a Budget?” form that you completed and will send in with your application.

____Complete the “CERTIFICATION OF INCOME” ONLY if any person 18yrs and older and has NO income. Please keep the “Energy Tips” page for your reference. Please include with your application:

1. Last month’s complete PG&E bill/Alameda Power Bill 2. Proof of gross monthly income for the past 30 days

3. Other necessary documentation, please see the cover sheet with requirements. INCOME GUIDELINES: (SSA/SSI 2017 award letters, bank statements, Pension & Annuities Award Letters, EDD, GA, Loans

from family members or friends: We will need a signed letter (and print their name below their

signature) with the amounts, dates and their telephone number. Self-employed: We will need signed

taxes (all pages) with the Schedule C or Ledger, or Receipt book with the last 30 days.)

Please contact us if you have questions at 510-881-0300.

Uncompleted applications WILL be sent back. Please send your applications and documents to:

Spectrum Community Services HEAP Program P.O. Box 4317 Hayward, CA 94540

Install these energy-efficient measures:

Replace your old refrigerator, washer/dryer, and dishwasher with energy-efficient models. Energy Star®

Buy a water heater that fits your needs.

Insulate ceilings.

Caulk windows, doors and anywhere air leaks in or out. Do not caulk around water heater and furnace exhaust pipes.

Weather-strip around windows and doors.

Wrap heating and cooling ducts with duct wrap.

Use compact fluorescent bulbs.

HEATING

Set the furnace thermostat at 68 degrees or lower during the day.

Health permitting set thermostat at 55 ° at night or off.

Have a professional inspect and tune up your furnace.

Clean or replace furnace filters once a month.

Check air vents, radiators, and registers.

Wear a sweater or clothing in layers to trap body heat.

Open drapes to let sun heat your home during the day and close them at night to help insulate.

Close off unused rooms and vents that heat those rooms.

Close your fireplace damper tightly when not in use.

Close doors and windows.

Replace old windows with new dual pane windows.

NEVER USE THE KITCHEN STOVE OR OVEN TO HEAT YOUR HOME (or use the BBQ)

COOLING

Set the thermostat at 78 degrees in summer or off.

Use a fan and natural ventilation first.

Wear cooler clothing.

ENERGY TIPS

WATER

Buy a water heater that fits your needs. Energy Star®

Turn down the water heater thermostat to120 ° F.

Insulate your water heater tank.

Install low-flow showerheads.

Take shorter showers.

Fix leaky water faucets and install low-flow aerators on the faucets.

Wash full loads in your dishwasher and use air-dry option on your dishwasher.

Wash full loads and use cold water when washing clothes.

Dry clothes outside in good weather.

OTHER WAYS TO SAVE ENERGY...

Turn off the lights.

Close off rooms and vents in those rooms not in use.

Unplug power adapters and chargers.

Never leave a space heater on when you go to sleep or leave the area.

Keep space heaters at least three feet from bedding, drapes, furniture, and other flammable materials.


PLEASE PRINT YOUR NAME: ____________________________________

CITY_______________________________________________________

Please tell us how you heard of the Home Energy Assistance Program (HEAP)

For Example:

Friends & Family Energy Company Flyer Organization

If an organization referred you, please write the name of the organization

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Thank you for your feedback


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