2015 LIHEAP - San Joaquin County Human Services Agency LIHEAP Application - For Print... · home energy assistance program (heap) Established in 1981, HEAP is a federally funded program

San Joaquin County Low Income Home Energy Assistance Program (LIHEAP)

333 E. Washington Street | Stockton, CA 95202 |PO BOX 201056 | STOCKTON, CA 95201 209-468-3988 | Toll Free 1-877-977-3988 | www.sjchsa.org

PARA ASISTENCIA EN ESPAÑOL: Por favor llame a la oficina

2015 LIHEAP UTILITY PAYMENT ASSISTANCE | HOME WEATHERIZATION

The Low Income Home Energy Assistance Program assists eligible households with the cost of home energy through two programs:

1. The Energy Program assists with a one-time payment of an electric/gas or propane energy bill once per program year.

2. The Weatherization Program provides free energy saving measures or repairs to homes that can help lower energy usage or utility costs.

Please complete all forms that apply, and sign all forms that require a signature.

Completing this application does not guarantee that you will be eligible for LIHEAP benefits. Please review the Program Facts on the back of this page.

Forms included in the packet:

1. Intake Application (3 PAGES – REQUIRED FOR ALL SERVICES):

a) Acknowledgement Form (CE CSD 321) b) Energy Intake Form (CSD 43) c) Statement of Citizenship or Non-Citizen Status for Public Benefits Form (CSD 600)

2. PG&E California Alternate Rates for Energy (CARE) Program Application (OPTIONAL – MONTHLY UTILITY DISCOUNT) 3. Application Instructions and Helpful Resources (PLEASE KEEP FOR YOUR RECORDS) 4. Energy Education and Home Budgeting Tips (PLEASE KEEP FOR YOUR RECORDS) 5. Weatherization Forms (OPTIONAL - NOT REQUIRED FOR UTILITY ASSISTANCE)

APPLICATION RETURN OPTIONS:

OFFICE LOCATION: HUMAN SERVICES AGENCY | 333 E. WASHINGTON STREET | STOCKTON, CA 95202

SELF SERVICE DROP BOX WINDOW 14 MAILING ADDRESS MONDAY – FRIDAY 8:00AM TO 5:00PM

***TUESDAY, WEDNESDAY, THURSDAY 9:00AM TO 12:00PM

ENERGY PROGRAM PO BOX 201056 | STOCKTON, CA 95201

***Window 14 days and hours of operation may vary upon the number of applicants waiting to be seen, and may be subject to change when maximum occupancy is reached; and may be subject to closure periodically based on staff availability and season.

PLEASE ALLOW 4 TO 6 WEEKS FOR PROCESSING. UTILITY ACCOUNT CREDIT CAN TAKE AN ADDITIONAL 4 TO 6 WEEKS.

THE ENTIRE PROCESS CAN TAKE UP TO 3 TO 4 MONTHS. YOU WILL RECEIVE A POSTCARD BY MAIL CONFIRMING THE RECEIPT OF YOUR APPLICATION.

ONLY APPLICATIONS THAT ARE COMPLETED IN FULL WITH ALL THE REQUIRED DOCUMENTS WILL BE PROCESSED.

SAN JOAQUIN COUNTY ENERGY PROGRAM FACTS

HOME ENERGY ASSISTANCE PROGRAM (HEAP)

Established in 1981, HEAP is a federally funded program that helps low-income households pay their energy bill. Assistance is in the form of a direct payment to a utility company on behalf of an eligible applicant. Eligibility is based on the household's total monthly income, which cannot exceed the HEAP income guidelines. Because of significant funding cuts, the federal government enacted a law requiring that states target households with low-incomes and high energy costs, taking into consideration households with elderly and disabled persons, and children under six. This means there could be households that received assistance in the past and will no longer receive assistance because they fall into a low priority group and are not considered among the neediest of the needy. The amount of assistance is based on the number of persons in the household, total household income, the cost of energy within the county the household resides, and funding availability. HEAP provides one payment per program year.

ENERGY PROGRAM COMPONENTS The Home Energy Assistance Program (HEAP) provides non-emergency assistance to eligible households. Once an application is processed and approved, a payment will be applied to the utility account (appearing as a credit on the utility bill in 2 to 3 billing cycles). The Energy Crisis Intervention Program (ECIP) provides immediate assistance to eligible households in an energy crisis that show proof of a 48 Hour or Shut-Off Notice. Once an application is processed and approved, a payment guarantee (pledge) will immediately be applied to the utility account. Wood, Propane, or Oil (WPO) customers may receive help with their energy bill if either of these are the primary source for heating or cooling the home.

DEFINITIONS/STATEMENTS: Qualification: To qualify for the program, an applicant must meet ALL of the following requirements: US Citizenship or Legal Residency, reside in San Joaquin County, meet household income requirements, and be responsible for energy costs in the home. Eligibility: To be eligible for benefits: 1) the applicant must submit a completed application with supporting documentation; 2) the household must meet the agency’s priority plan requirements to receive program benefits. Agency Priority Plan: In accordance with federal law, agencies must ensure that the highest level of priority will be given to those households which have the lowest incomes and the highest energy need taking into account family size and vulnerable populations (very young children, individuals with disabilities, and the elderly). Fraud: Fraud consists of false statements or misrepresentation of facts; or the willful withholding of information for the purpose of obtaining assistance to which an applicant/household is not eligible. Appeal: Applications that are considered “denied” are appealable, and applicants are advised of their appeal rights. Applications that are considered “ineligible” are not appealable. Examples of non-appealable applications: Agency is out of funds, the new program year has not started, or your household does not meet the Agency Priority Plan.

HOW TO APPLY AND WHAT TO SEND WITH YOUR APPLICATION

* * * COMPLETE AND SUBMIT ONLY ONE APPLICATION * * *

All documentation must be current within 30 days of the date of your application.

1. Complete, sign and date all the forms (front and back). This is required in order to process your application. 2. Answer every question on the application that applies to you (avoiding the sections above and below for official use only). Sections left blank will cause a delay in processing your application. 3. Include a copy of your current energy bill. IF YOU HAVE A DELINQUENT NOTICE, INCLUDE IT. You may be able to get immediate assistance to avoid being shut off. 4. Include a copy of your birth certificate or proof of legal residency. A driver’s license or social security card is not acceptable proof of citizenship. 5. Include a copy of current gross income for ALL members of the household. Issue or pay dates must cover the last 30 consecutive days (weekly, bi-weekly, monthly) with no gaps. Adults 18 years of age or older, included in the household count, must provide proof of income. Adult household members with zero income must complete a Certification of Income and Expenses Form CSD 43B and include it with the application. Failure to do so will result in delay or denial of your HEAP application. 6. Submit your application by mail using the postage paid envelope, or bring your application to:

HUMAN SERVICES AGENCY 333 E. WASHINGTON STOCKTON, CA 95202

MONDAY THROUGH FRIDAY 8:00AM TO 5:00PM

* * * I M P O R T A N T * * * Your LIHEAP application is not a commitment that your bill will be paid. If you are eligible for the program while funds remain available, a payment will be sent directly to your utility company (or directly to the recipient for sub-metered accounts). Meanwhile, please keep paying as much of your bill as soon as you can to avoid penalties such as disconnection/reconnection fees, additional deposits, interest, late charges, or having your power shut off.

Keep paying your energy bill as you normally would

to avoid being shut off or non-delivery of fuel. Make payment arrangements with your utility company if necessary, to avoid interruption.

If you have questions or need help in completing this application, call:

209-468-3988 OR Toll Free 1-877-977-3988

Or visit the HEAP Homepage at:

www.sjchsa.org

SAN JOAQUIN COUNTY | HELPFUL RESOURCES 

*     *     *     ENERGY ASSISTANCE     *     *     *  

Pacific Gas and Electric Company‐ 1‐800‐743‐5000 California Alternate Rates for Energy (CARE), Family Electric Rate Assistance (FERA), Medical Baseline Allowance (Life  Support), Energy Partners (Free Home Improvements).  Lodi Electric U lity | 209‐333‐6762 Single Household Alterna ve Rate for Energy (SHARE) Residen al Medical Discount Program  Modesto Irriga on District (MID) | 209‐526‐7373 Community Alterna ve Rates for Electric Service (CARES), Residen al Life Support Services.  Salva on Army REACH REACH is a one‐ me energy‐assistance program sponsored by PG&E and administered through the Salva on Army from 170 offices in northern and central California.   

Stockton | 209‐948‐8955 Lodi | 209‐369‐5896 Tracy | 209‐836‐2346    

California Public U li es Commission (CPUC) | 1‐800‐649‐7570 If your energy, telephone, or water has been shut off because you fell behind on your bills, the CPUC may be able to help you get your services restarted.   

  *     *     *     COMMUNITY CONNECTION     *     *     *  

INFORMATION AND ASSISTANCE  

San Joaquin County Aging and Community Services Informa on and Assistance Program 209‐468‐1104 | 1‐800‐510‐2020 

 Community Ac on Centers (CAC’s) 

 For over  twenty‐five  years,  the  San  Joaquin Community Centers have been providing  a wide variety of direct and referral services to individuals and families through a network of eight  (8)  community  centers.   Center  staff provides  linkage and  referrals  to agencies  to assist  individuals  and  families  in  the  areas  of  human  services,  employment,  health,       nutri on, housing assistance and educa on services. 

Boggs Tract Center 533 S. Los Angeles Avenue 

Stockton, CA 95203  (209) 468‐3978 

Garden Acres Center 607 Bird Avenue 

Stockton, CA 95215 (209) 468‐3984 

Kennedy Center 2800 S. ‘D ‘Street Stockton, CA 95206  (209) 468‐3986 

Larch Clover Center 11157 W. Larch Road 

Tracy, CA 95376 (209) 831‐5920 

Lodi Center 415 S. Sacramento Street 

Lodi, CA 95240 (209) 331‐7516 

Northeast Center 2885 E. Harding Way Stockton, CA 95205  (209) 468‐3918 

Ta  Center 389 W. Downing Avenue 

Stockton, CA 95206 (209) 468‐4168 

Thornton Center 26675 N. Sacramento Blvd 

Thornton, CA 95686 (209) 794‐2144 

The Weatheriza on Program provides  services designed  to  reduce hea ng and  cooling  costs  and  improve  the  energy  efficiency  of  a  home,  while safeguarding  the  health  and  safety  of  the  household.  *If  you  qualify  for HEAP, you AUTOMATICALLY qualify for Weatheriza on. 

No‐cost energy saving measures may include (if dwelling qualifies):  

Digital Thermostat Carbon Monoxide Detector 

Ceiling Insula on Door Weather‐stripping 

Window Repair/Replacement CFL Light Bulbs Showerhead 

Refrigerator/Gas Range Replacement Heater Repair/Replacement 

Hot Water Heater Repair/Replacement 

*Subject to household and dwelling eligibility. Contact the office for requirements. 

H O M E   E N E R G Y   C O N S E R V A T I O N   T I P S Consider these energy saving  ps to help lower monthly energy costs. 

San Joaquin County LIHEAP | PO Box 201056, Stockton CA 95201 | 209‐468‐3988 | 1‐877‐977‐3988 | www.sjchsa.org 

Budget Box System 

The budget box  is a small box with dividers for each day of the month, with one divider for each day of the month.  When you  receive a bill, check  the due date and place  it behind  the divider that represents the bill’s due date.  As you receive income, pay all bills that are due. 

Computer System 

If  you  have  access  to  a  personal  computer,  you  can  create  your  own      spreadsheet (like the one pictured to the right). You may also find free budge ng tools on the internet. CAUTION: Only visit reputable sites, such as mymoney.gov.  You  may  also  want  to  purchase  a  personal  finance  program.    They  are       available for less than $75.  Using a computer to manage your finances is rela vely simple.  Once you set up  the system, upda ng  informa on  is quick and easy.    It  is  important  to enter transac ons frequently to truly understand your financial posi on. 

Envelope System 

This tool is useful if you pay your bills in cash each month.  Make an envelope  for each expense  category,  such as  rent, gas, electricity, and food.  Label the envelope with the name of the category, the amount, and the due date.  When you receive  income, divide  it  into the amounts to cover  the expenses listed on the envelope.  Pay  bills  right  away  so  you  will  not  be  tempted  to  spend  the money  on    something else. 

For these and other resources, visit www.mymoney.gov.

H O M E   B U D G E T I N G   T I P S A budget is a tool to help you plan, priori ze, and manage your income and expenses.   

Review your budget o en and update it when you are experiencing a change in income and expenses. Consider these helpful tools: Sample Household Budget 

(FOR INFORMATION ONLY ‐ PLEASE KEEP FOR YOUR RECORDS)               Income             Wages     $_________       Public Assistance     $_________       SSA/SSI     $_________       Pension     $_________       Other     $_________       

Total Income        $________               Fixed Expenses          Rent/House Payment     $_________       Insurance (Life/Auto/Home)     $_________       Savings     $_________       Credit/Loans/Other     $_________       Total        $________                  Flexible Expenses          U li es (Electric/Gas/Water)     $_________       Food     $_________       Health/Medical     $_________       Phone/Cell     $_________       Cable     $_________       Transporta on/Gas     $_________       Other     $_________       Total        $________                  

Total Expenses     $________               Total Income Minus Total Expenses Equals:               

Cash Flow        $________ 

San Joaquin County LIHEAP | PO Box 201056, Stockton CA 95201 | 209‐468‐3988 | 1‐877‐977‐3988 | www.sjchsa.org 

APPLICATION FORMS

COMPLETE AND RETURN WITH REQUIRED DOCUMENTS.

San Joaquin County Human Services Agency LOW INCOME HOME ENERGY ASSISTANCE PROGRAM 2015

(LIHEAP)

ACKNOWLEDGMENT FORM (CE-CSD 321)

The San Joaquin County Low Income Home Energy Assistance Program (LIHEAP) is able to assist San Joaquin County residents with gross household incomes at or below 200% of the federal poverty level.

2015 Income Guidelines at 60% of State Median Income (SMI)

1 2 3 4 5 6 7 8 9 10

1996.89 2611.31 3225.74 3840.17 4454.59 5069.02 5184.23 5299.43 5414.64 5529.84

Applicant Responsibilities: 1. File an application with complete and correct information. 2. Verify income is at or below 100% of the federal poverty level (SEE INCOME GUIDELINES). 3. Verify household composition (by reporting total number of household members). 4. Report and submit supporting documentation for ALL of the following (SEE DOCUMENATION CHECKLIST ON BACK PAGE):

• US citizenship or legal residency for applicant only. • Current total gross income for all members of the household. • Current energy costs.

5. Review the Home Energy Conservation and Home Budgeting Fact Sheets. San Joaquin County LIHEAP Responsibilities: 1. Review completed applications and determine qualification based on program criteria. 2. Determine eligibility for benefits based on program guidelines and the agency’s priority plan approved by the State of California. 3. Assist eligible households by processing applications for “one time” (once per year) payment of electric/gas or propane utility bills as funds are available. Applicant Signature Date Applicant Name (Print) Email Address (OPTIONAL)

PO BOX 201056 | STOCKTON, CA 95201 209-468-3988 | Toll Free 1-877-977-3988 | www.sjchsa.org

DOCUMENTATION CHECKLIST All information that applies to your household must be submitted before your application can be reviewed. Please check off submitted documents.

Please send copies. Originals will not be returned. ALL DOCUMENTS MUST BE CURRENT WITHIN 30 DAYS OF APPLICATION DATE

Energy Bill:

• PG&E bill (all pages), Lodi Electric Utility (all pages), Modesto Irrigation District (all pages), Propane utility invoice.

• FOR DELINQUENT/OR SHUT-OFF ACCOUNTS: PG&E Account Information Sheet; Pink or yellow notice AND regular City of Lodi bill; delinquent bill for all others.

Current Gross Earnings for the last thirty (30) days for all household members:

• Temporary Assistance for Needy Families (TANF): Notice of Action; computer printout; benefit letter; copy of welfare check;

• Supplemental Security Income (SSI): Notice of Planned Action or Form 2458; computer printout from Social Security Office; copy of bank statement showing SSI direct deposit; copy of SSI check;

• Social Security (SSA): copy of current check(s); SSA Form 4926, or 2458; computer printout from Social Security Administration Office; Bank Statement showing direct deposit;

• Pension and Annuities: copy of a current check; verification on letterhead or annual statement from pension plan dated for the current year;

• Wages: Copy of current paycheck stub(s) covering a one-month period and showing gross income;

• Interest Income: monthly or quarterly bank statement; statement of interest income from bank or agency;

• Disability Compensation: copy of a current check; printout or letter from agency or insurance company verifying the compensation amount;

• Unemployment Benefits: copy of current check(s) or stubs; printout from Employment Development Department;

• Child and/or Spousal Support: copy of current benefit statement or check; • Support from an Individual: copy of check and statement signed by person providing the

support; • General Assistance: Notice of Action from County Social Services; copy of a current check; • Veteran’s Benefits: letter indicating receipt of Veteran’s Pension; copy of Veteran’s

Administration check; • Current signed Federal Tax Form 1040 and Schedule C: ONLY FOR SELF-EMPLOYED

(2013 Federal Tax Form 1040 valid through April 15, 2015) • ALL ADULTS IN THE HOUSEHOLD, 18 YEARS OR OLDER, WITH ZERO INCOME: Will

need to complete Form CSD 43B - Certification of Income and Expenses. Contact the office, or pick up this form at HEAP Intake Window 14, or on the HEAP Home Page @ www.sjaging.org.

Proof of US Citizenship or Legal Residency: US Birth Certificate Current United States Passport Form N-561 Certificate of Citizenship Valid Form I-551 Alien Registration Card

THIS IS A PARTIAL LISTING OF ACCEPTABLE DOCUMENTS. CONTACT OFFICE FOR ADDITIONAL INFORMATION.

PO BOX 201056 | STOCKTON, CA 95201

209-468-3988 | Toll Free 1-877-977-3988 | www.sjchsa.org

1 5 2 0 4 0 0 0 0

Agency: Intake Initials: Intake Date: Eligibility Cert Date:First Name Middle Initial Last Name Date of Birth

M M D D Y Y

Mailing Address Check if same as service address Unit Number

Mailing City Mailing State Mailing ZIP Code

Service Address (Do not use P.O. Box) Unit Number

Service City Service State Service ZIP Code

Social Security Number (SSN): Message Only?

UTILITY BILL DISCOUNT

Which utility company do you want paid?

TANFSSI/SSP Account Number:SSA/SSDIPaycheck(s)Interest Name of customer on the utility bill:PensionOther

$

* Questions 1-5 (below) are MANDATORY fields.

Applicant: Do not fill out the information below. This section is for official use only. HEAP Fast Track Supplement $__________

HEAP WPO ECIP WPO Referral --> Home referred for weatherization Referred for ECIP HCS Home already weatherizedWeatherization being billed under which program --> DOE LIHEAP WX ECIP HCSType 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 unitsSFD - Rental, 1 unit MFD - Owner, 5 or more units

MFD - Rental, 5 or more units

Check here if utilities are all electric

5. Are you or someone in your household CURRENTLY receiving CalFresh (Food Stamps)?

4. If you chose PROPANE, FUEL OIL, WOOD, KEROSENE or OTHER FUEL in Question 1:

Are you currently out of fuel?

Approximately how many days until you run out of fuel completely …………….…(enter number of days) :

Priority OffsetsHard To ReachAgency Defined Priorities:

The 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 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.

Date

Medically Needy Frail Elderly Severe Financial Hardship

Witness' Signature (if signed with an X)

Ages 60 or older (Elderly)

$

Check here if your utilities are included in rent or sub-metered.

Applicant's Signature

TOTAL INCOME

$

SJC AGING AND COMMUNITY SERVICES

$

Seasonal or Migrant Farmworker

Disabled

1. What is the main fuel you use to HEAT your home? (SELECT ONLY ONE )

2. In addition to the main heating fuel you listed in Question 1, do you ever use any of the following to HEAT your home (you can check more than one):

3. If you chose NATURAL GAS or ELECTRICITY in Question 1:

Do you currently have a past due notice?

A.C.C.

Job Control Code

Department of Community Services and Development

PEOPLE LIVING IN HOUSEHOLD

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

Energy Intake FormCSD 43 (12/2014)

PriorityPoints:

2 years old or younger

Cash Assistance being provided under which program -->

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.

Is your gas or electricity currently shut off / disconnected?

$Native AmericanLimited-English Speaking

CA

Enter the number of people who are:

Ages 3 - 5 yearsAges 6 - 18 years

Enter the total number of household members who

receive income -->

You may be eligible for a discount on your monthly utility bill! Contact your local utility company and ask about reduced rate programs.

INCOME

Telephone Number: ( )

Service County SAN JOAQUIN

Mailing County

Total Benefit $__________________

$$$Ages 19 - 59 (Adult)

Enter the total numberof people living in the

household, including theapplicant -->

Energy Cost = $ Energy Burden = %

Natural GasElectricity

Propane

Fuel Oil UnknownOther Fuel

Electricity (such as space heaters) Wood (in a fireplace or wood stove)

YES NO

YES NO

YES NO

WoodKerosene

N/A

N/A

YES NO N/A

N/A

N/A

1 5 2 0 4 0 0 0 0

Agency: Intake Initials: Intake Date: Eligibility Cert Date:Nombre Inicial Apellido Fecha de Nacimiento

M M D D Y Y

Domicilio Postal Marque si es igual que la direccion del servicio Número de Unidad

Ciudad (de su domicilio postal) Condado Estado Código Postal

Domicilio en que se recibe el servicio de energia (No use Apartado Postal - P.O. Box) Número de Unidad

Ciudad (en que se recibe el servicio) Condado Estado Código Postal

Número de Seguro Social (SSN): Mensaje

DESCUENTO DE UTILIDADES

Cuál compañía de servicios de energía le gustaría que se pague?

TANFSSI/SSP Número de Cuenta:SSA/SSDISueldo(s)Interés Nombre del cliente (como aparece en la factura):PensiónOtros Ingresos

$

* Preguntas 1-5 (abajo) son obligatorios.

Solicitante: No complete la siguiente información. Esta sección es sólo para uso oficial. HEAP Fast Track Supplement $__________

HEAP WPO ECIP WPO Referral --> Home refered for weatherization Referred for ECIP HCS Home already weatherizedWeatherization being billed under which program --> DOE LIHEAP WX ECIP HCSType 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 unitsSFD - Rental, 1 unit MFD - Owner, 5 or more units

MFD - Rental, 5 or more units

Firma del Solicitante Fecha Firma del Testigo (si firmó con una X)NOMBRE DE LA AGENCIA: Departamento de Servicios y Desarrollo de la Comunidad (CSD). UNIDAD RESPONSABLE DE MANTENIMIENTO: Programa de Ayuda para la Energía del Hogar (HEAP). AUTORIDAD: El código gubernamental, Sección 16367.6 (a) designa a CSD como la agencia responsable de la administración de HEAP. OBJETIVO: La información que proporcione se usará para determinar si usted reune los requisitos para recibir el pago de LIHEAP, y/o servicios de weatherization. PROPORCIONANDO INFORMACION: La participación en este programa es voluntaria. Si decide solicitar esta ayuda, debe proporcionar toda la información requerida. INFORMACION ADICIONAL: CSD utiliza definiciones estadísticas de la autualización anual de las Pautas de Ingresos Federales de Pobreza del Departamento de Salud y Servicios Humanos para determinar la aceptación de una persona en los programas. Durante el trámite de su solicitud, es posible que el subcontratista designado por CSD necesite pedirle información adicional para determinar si se le puede aceptar en estos u otros programas. ACCESO: El subcontratista designado por CSD se quedará con su solicitud, y otra información, si se usó para determinar su eligibilidad. Usted tiene derecho de acceso a todos los expedientes que contengan información sobre usted. CSD no discrimina en los servicios que ofrece debido a raza, religión, credo, color, origen de nacionalidad, incapacidad física, incapacidad mental, condición médica, estado marital, sexo, edad, o orientación sexual.

Aproximadamente cuántos días hasta que se quede sin combustible completamente (Introduzca el número

5. ¿Usted o alguien en su casa ACTUALMENTE recibe CalFresh (estampillas de comida)?

¿Está actualmente fuera de combustible?

Total Benefit $__________________

Marque aqui si sus servicios están incluidos en la renta o sub-medido

Marque aqui si sus utilitdades es solo electricidad

4. Si elegiste propano, aceite combustible, madera o otra combustible en la pregunta 1:

¿Es el gas o la electricidad actualmente apagado o desconectado?

La información en esta solicitud será usada para determinar y verificar mi elegibilidad para recibir ayuda. Con mi firma doy autorización para que esta información sea compartida con otras oficinas del Gobierno Estatal y Federal, subcontratistas designados por ellos, con la(s) compañía(s), que me ofrece(n) servicio(s) de energía y para que la(s) compañía(s) que me ofrece(n) servicio(s) de energía comparta(n) información con otras oficinas del Gobierno Estatal y Federal con el fin de proporcionar servicios a mí y a coordinar, mejorar y reducir los costes de servicios bajo estos programas. Además autorizo a mi compañía (s) utilidad para proporcionar mis datos de consumo de energía a CSD en la medida necesaria para CSD para cumplir con el programa informando los requisitos del gobierno federal. Entiendo que si mi aplicación para beneficios o servicios de LIHEAP/DOE se niega, o si recibo una respuesta retrasada, puedo iniciar una apelación escrita con el proveedor de servicios local y mi apelación se revisará no mas que 15 días después de que la apelación se solicita. Si yo no estoy satisfecho con la decisión del proveedor de servicios entonces puedo apelar al Departamento de Servicios y Desarrollo de la Comunidad (CSD) conforme al Titular 22, Código de California sección 100805. En caso de ser elegible, doy permiso para la instalación de material aislante en mi residencia sin costo alguno para mí. Declaro, bajo pena de perjurio, que la información declarada en esta solicitud es correcta y verdadera, y que los fondos recibidos serán usados únicamente con el objetivo de pagar mis gastos de consumo de energía.

Cash Assistance being provided under which program -->

Priority OffsetsHard To ReachAgency Defined Priorities: Medically Needy Frail Elderly Severe Financial Hardship

Limited-English SpeakingAmericanos Nativos

Campesinos Temporales/Migratorios

INGRESOS TOTAL (en bruto)

$$$

SAN JOAQUINNúmero de Teléfono: ( )

INGRESOS

Escriba el número de personas en el hogar que

reciben ingresos -->:

PriorityPoints:

SJC AGING AND COMMUNITY SERVICES

Department of Community Services and Development

Escriba el total del ingreso mensual, en bruto, de todas las personas que viven en su hogar:

A.C.C.

Job Control Code

Energy Intake FormCSD 43 (12/2014)

PERSONAS VIVIENDO EN EL HOGAR

Escriba el número de personas en su hogar:De 2 años o menores

Incluyendo al solicitante,escriba el número de

personas que viven en su hogar --> :

1. ¿Cuál es el principal combustible que se utiliza para calentar su casa? (SELECCIONE SÓLO UNA)

2. Además de la principal combustible para calefacción que figuran en la pregunta 1, ¿usas alguno de los siguientes para CALENTAR su hogar (puede marcar más de una):

3. Si eligió gas natural o electricidad en la Pregunta 1:

¿Tiene actualmente un aviso de pago atrasado?

$$

CA

Incapacitados

Usted también puede ser elegible para un descuento en su factura mensual! Comuníquese con su compañía de servicios y pregunta sobre los programas de tarifa reducida.

De 3 años a 5 añosDe 6 años a 18 añosDe 19 años a 59 añosDe 60 años o mayores

$$

Energy Cost = $ Energy Burden = %

Gas NaturalElectricidad

PropanoAceite Combustible No lo se

Otro combustible

Electrididad (como calendor de espacio) Madera (en un chimenea o estufa de madera)

SI NO

SI NO

SI NO

SI NO

Queroseno

Madera

N/A

N/A

N/A

N/A

N/A

State of California Page 1 of 2

1. Is the applicant a citizen or national of the United States? Yes NoCity/State

2.

1.

2.

3.

4.

INS Form I-94 with stamp showing admission for at least one year under section 212(d)(5) of the INA. (Applicant cannot aggregate periods of admission for less than one year to meet the one-year requirement.)

INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”;INS Form I-766 (Employment Authorization Document) annotated “A3”; orINS Form I-571 (Refugee Travel Document)

An alien paroled into the United States for at least one year under section 212(d)(5) of the INA. Evidence includes:

Grant letter from the Asylum Office of INS; orOrder of an immigration judge granting asylum.

A refugee admitted to the United States under section 207 of the INA. Evidence includes:INS Form I-94 annotated with stamp showing admission under section 207 of the INA;

An alien who is granted asylum under section 208 of the INA. Evidence includes:INS Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA;INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(5)”;INS Form I-766 (Employment Authorization Document) annotated “A5”;

Important: Please indicate the applicant's non-citizen status below, and submit documents evidencing such status. The no citizen status documents listed for each category are the most commonly used documents that the United States Immigration and Naturalization Service (INS) provides to non-citizens in those categories. You can provide other acceptable evidence of your non-citizen status even if not listed below.

An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA). Evidence includes:

INS Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”); orUnexpired Temporary I-551 stamp in foreign passport or on INS Form I-94.

To establish citizenship or naturalization, please submit one of the documents on List A (attached hereto) which is legible and unaltered to establish proof.

If you are a Citizen or National of the United States, please go directly to Section D . If you are a Non-Citizen, please complete Section B, or, if applicable, Section C .

Section B: Non-Citizen Status Declaration

Non-Citizens who meet all eligibility requirements may receive services under the Low-Income Home Energy Assistance Program and/or the Department of Energy Low-Income Weatherization Assistance Program and must complete Sections A, B or C, and D.

Section A: Citizenship/Non-Citizen Status Declaration

If the answer to the above question is yes, where was he/she born?

Public Benefits To Citizens And Non-CitizensCitizens and Nationals of the United States who meet all eligibility requirements may receive services under the Low-Income Home Energy Assistance Program and/or the Department of Energy Low-Income Weatherization Assistance Program and must fill out Sections A and D.

Name of Person Acting for Applicant, if any Relationship to Applicant

DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENTCSD 600 (Rev. 3/24/06)

Name of the Applicant Requesting Energy Services DateSTATEMENT OF CITIZENSHIP or NON-CITIZEN STATUS FOR PUBLIC BENEFITS

CSD 600 (Rev. 3/24/06) Page 2 of 2

5.

6.

7.

8.

9.

10.

1.

2.

Attachments: Lists A and B

Signature of Person Acting for Applicant Date

Section D: CertificationI DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE ANSWERS I HAVE GIVEN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.Applicant's Signature Date

Section C: Declaration for Certain Battered AliensImportant: Complete this section if the applicant, the applicant's child, or the applicant child’s parent has been battered or subjected to extreme cruelty in the United States by a spouse or parent.

Has the INS or the EOIR granted a petition or application filed by or on behalf of the applicant, the applicant’s child, or the applicant child’s parent under the INA or found that a pending petition sets forth a prima facie case for granting permission to stay in the United States? Evidence includes one of the documents on List B (attached hereto).Has the applicant, the applicant's child, or the applicant child’s parent been battered or subjected to extreme cruelty in the United States by a spouse or parent, or by a spouse's or parent's family member living in the same house (where the spouse or parent consented to or acquiesced in the battery or cruelty)?

INS Form I-94 with stamp showing parole as “Cuban/Haitian Entrant” under section 212(d)(5) of the INA; or paroled after 10/10/80 in the special status for nationals of Cuba or Haiti.

An alien paroled into the United States for less than one year under section 212(d)(5) of the INA. (Evidence includes INS Form I-94 showing this status.)An alien not in categories 1 through 8 who has been admitted to the United States for a limited period of time (a nonimmigrant). Non-immigrants are persons who have temporary status for a specific purpose. (Evidence includes INS Form I-94 showing this status.)I self-certify that I am a U.S. citizen or non-citizen national or qualified alien but am unable to provide documentation. (Only allowable under the Energy Crisis Intervention Program (ECIP) component of the LIHEAP Program.)

INS Form I-766 (Employment Authorization Document) annotated “A3.”An alien who is a Cuban or Haitian entrant (as defined in section 501(e) of the Refugee Education Assistance Act of 1980). Evidence includes:

INS Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with the code CU6, CU7, or CH6;Unexpired temporary I-551 stamp in foreign passport or on INS Form I-94 with the code CU6 or CU7; or

Order from an immigration judge showing deportation withheld under section 243(h) of the INA as in effect prior to April 1, 1997, or removal withheld under section 241(b)(3) of the INA.

An alien who is granted conditional entry under section 203(a)(7) of the INA as in effect prior to April 1, 1980. Evidence includes:

INS Form I-94 with stamp showing admission under section 203(a)(7) of the INA;INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”; or

An alien whose deportation is being withheld under section 243(h) of the INA (as in effect prior to April 1, 1997) or section 241(b)(3) of such Act (as amended by section 305(a) of division C of Public Law 104-208). Evidence includes:

INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(10)”;INS Form I-766 (Employment Authorization Document) annotated “A10”; or

Apply for a monthly discount on your PG&E bill

CARE/FERA PROGRAM APPLICATION

Residential Customers

*Total gross annual household income includes all taxable and nontaxable revenues from all people living in the home, from whatever sources derived, including, but not limited to, wages, salaries, interest, dividends, spousal and child support payments, public assistance payments, Social Security and pensions, housing and military subsidies, rental income, income from self-employment and all employment-related, non-cash income.

California Alternate Rates for Energy

(CARE)

pge.com/CARE

1-866-743-2273

The CARE Program offers a monthly

discount on PG&E bills for qualifying

households. Qualification is based on

the total income of everyone living in

the home OR participation in qualifying

public assistance programs.

Please look over the CARE Income

Guidelines listed here to see if you

qualify. On the application form, you can enroll by:

• Checking all the qualifying public assistance programs from

which you, or someone in your household, receive benefits OR

• Checking the box that matches your household’s total gross

annual income.*

Family Electric Rate Assistance

(FERA)

pge.com/FERA

1-800-743-5000

If you do not qualify for

the CARE Program, you

may still qualify for the

FERA Program, which

offers a monthly discount

on electric bills for

households of three or

more people with a

slightly higher income

than required for CARE.

See the FERA Income Guidelines listed above to find out

if you qualify, and enroll by completing the included

application.

Number of People in Household

Each AdditionalPerson, add

1-2 $31,460 or less

3 $39,580 or less 4 $47,700 or less 5 $55,820 or less 6 $63,940 or less 7 $72,060 or less 8 $80,180 or less $8,120

Total GrossAnnual HouseholdIncome*

CARE Income Guidelines(good until May 31, 2015)

Number of People in Household

Each AdditionalPerson, add

1-2 Not Applicable3 $39,581–$49,4754 $47,701–$59,6255 $55,821–$69,7756 $63,941–$79,9257 $72,061–$90,0758 $80,181–$100,225 $ 8,120–$10,150

Total GrossAnnual HouseholdIncome*

FERA Income Guidelines(good until May 31, 2015)

Online: Apply online for

faster enrollment at

pge.com/CARE

Phone: Apply by calling

1-866-743-2273

Email: Take a picture or scan completed

application and email this image to

[email protected]

Fax: Send completed application

to 1-877-302-7563

Mail:

Send completed application to

CARE/FERA Program

P.O. Box 7979

San Francisco, CA 94120–7979

Other Helpful Programs and Services

Energy Savings Assistance Program

pge.com/ESA

1-800-989-9744

This program provides

energy-efficient home

improvements and appliances at no cost to

customers who qualify for CARE and rent

or own a home that is at least five years old.

My Energy

pge.com/MyEnergy

Log on to My Energy to sign up for billing and

payment alerts, analyze your household’s

energy usage, pay your bills and learn more

about your rate plan options.

Balanced Payment Plan

pge.com/BalancedPayment

1-800-743-5000

Your monthly payments will be averaged

out to allow you to budget your energy

costs and minimize big payment swings.

Medical Baseline

pge.com/MedicalBaseline

If you depend on life-support or other

equipment due to medical needs, you

may be eligible for additional energy at

the lowest price through the Medical

Baseline Program.

How You Can Apply

01-9077Rev. 6.14

Speech or hearing impaired? TDD/TTY is available at 1-800-652-4712 (9 a.m. to 11 p.m., Monday-Friday). Can’t use the TDD line? Call 1-800-735-2929

Low Income Home Energy Assistance

Program (LIHEAP)

1-866-675-6623

If you spend a high percentage of your income

on energy bills, you may be eligible to receive

financial assistance and weatherproofing

services through this program administered

by the California Department of Community

Services and Development.

Universal Lifeline Telephone Service (ULTS)

Get discounted telephone access when you

meet similar income guidelines as the CARE

Program. To learn more, contact your local

phone service provider.

01-9077Rev. 6.14

Your Name (Use the name as it appears on your PG&E bill, which must be in your name.)

Your Home Address (Address must be your primary residence. Do NOT use a P.O. Box.) Unit #

City/State/Zip Code

Email Address

1 You and Your Household

Your PG&E Account Number (Find yours on page 1 of your PG&E bill.)

3 Your Declaration

Adults + Children = (under 18)

Number of people in your household at this address:

X

Please fill out the information below about you and your household, and then the information for EITHER Section 2A OR 2B.

Sign and date this form and return it to PG&E as soon as possible. If you qualify, your CARE or FERA discount will appear on

the first page of your PG&E bill within the next two billing cycles.

––

–

––

Preferred Phone Number Home Work Mobile

Alternative Phone Number Home Work Mobile

Fill in circle if you’re a guardian or you have power of attorney

I also agree to the following program terms and conditions in order to remain eligible for the CARE or the FERA Program:

1. The information I have provided here is true and correct.

2. The PG&E bill is in my name, and I live at the address where the discount will be received.

3. I am not claimed as a dependent on another person’s income tax return other than my spouse.

4. I do not share an energy meter with another home.

5. I will renew my eligibility at least every two years and/or notify PG&E if my household is no longer eligible for the CARE or FERA discount.

6. Following enrollment, I understand I may be required to provide proof of qualifying household income which, in some cases, may require providing IRS Tax Return Transcripts and agreeing to participate in the Energy Savings Assistance Program.

7. I understand my monthly electric usage must not exceed six times the Tier 1 allowance, which is the lowest-priced rate tier within PG&E’s standard Tiered Base Plan.

8. I will pay back the discount if any of the information provided above is untrue.

9. I will allow PG&E to share my information with municipal, state or federal agencies, and/or other utilities or their agents, for the sole purpose of facilitating enrollment in their assistance programs.

By signing this declaration, I certify that based on

my household size and household income I qualify

for either the CARE or the FERA Program.

Customer Signature

Date

“PG&E” refers to Pacific Gas and Electric Company, a subsidiary of PG&E Corporation. ©2014 Pacific Gas and Electric Company. All rights reserved. These offerings are funded by California utility customers and administered by PG&E under the auspices of the California Public Utilities Commission.

FOR INTERNAL USE ONLY

Household Qualification2

What’s your preferred method of communication? (Choose one)

If your household meets the Program Income Guidelines, either fill

out Section 2A OR Section 2B. You do not need to complete both

sections. You will be enrolled in either the CARE or the FERA Program,

depending on your household income and household size.

What language do you prefer for future

CARE and FERA communications? (Choose one)

I am currently on a fixed income and receive income or benefits from one or more of the following: pensions, Social Security, SSP or SSDI, interest/dividends from retirement accounts, Medicaid/Medi-Cal (age 65 and over) or SSI.

Household Income 2B

OR

My household income is:

If you checked any of the boxes in this section, skip to Section 3.

If you do not participate in any of the above programs, please add up all the

income from every household member and check the box below that matches

your household’s total annual gross income. Please note the income ranges

listed below ARE NOT fixed incremental amounts, so carefully review each

income range before selecting the appropriate box.

$0–$31,460

$31,461–$39,580

$39,581–$47,700

$47,701–$49,475

$49,476–$55,820

$55,821–$59,625

$80,181–$88,300

$88,301–$90,075

$90,076–$96,420

$96,421–$100,225

Other $

$59,626–$63,940

$63,941–$69,775

$69,776–$72,060

$72,061–$79,925

$79,926–$80,180

CARE/FERA PROGRAM APPLICATION

Residential Customers

Mail Email Phone Text (Message and data rates may apply.)

English Hmong Tagalog Mandarin Cantonese

Russian Korean Vietnamese Spanish

Public Assistance Programs Check all the programs in which you, or someone in your household, participate.

Low Income Home Energy CalFresh/SNAP (Food stamps)

Assistance Program (LIHEAP) Women, Infants, and Children (WIC)

Bureau of Indian Affairs Supplemental Security Income (SSI)

General Assistance Medicaid/Medi-Cal (under age 65)

National School Lunch Program (NSLP) Medicaid/Medi-Cal (age 65 and over)

CalWORKs (TANF) or Tribal TANF Head Start Income Eligible (Tribal only)

Medi-Cal for Families (Healthy Families A&B)

2A

0

WEATHERIZATION COMPLETE THESE FORMS IF YOU ARE INTERESTED IN

WEATHERIZATION SERVICES FOR YOUR HOME. THESE FORMS ARE NOT REQUIRED FOR UTILITY ASSISTANCE PAYMENT.

Check the chart below to see if you qualify for this

free service:   

2015 Income Guidelines 

For more information, please call 209‐468‐0439. 

www.sjchsa.org 

As a renter or homeowner, you may be eligible to have 

your home or mobile home receive 

money‐ saving weatherization services at no cost to you. 

What is Weatherization? It is doing work to a home to protect it  from sunlight, rain and wind.  It will help reduce energy usage and increase energy efficiency.  

San Joaquin County’s Weatherization Program provides these services for  

FREE to qualified homes and individuals.    

Items such as:  Window (glass only) repair or replacement  Door repair or replacement  Free refrigerator, microwave, gas stoves  Heating/Air Conditioning repair or 

replacement  Insulation  Water Heater repair or replacement  Ceiling fans  Shower heads  Smoke Detectors  Carbon Monoxide Detectors  Digital Thermostat  Weather‐stripping 

# People

in Home*

Annual

Income

Monthly

Income

1 $23,963 $1,996.89

2 $31,336 $2,611.31

3 $38,709 $3,225.74

4 $46,082 $3,840.17

San Joaquin County Human Services Agency Our mission is to lead in the creation and delivery of services that improve the quality of life in our community. 

*For homes with more than 5 people, please call. 

Voltear la página en Español. 

Lower your Energy Bill for 

Revise la tabla de ingreso Para ver si califica para este servicio

gratuito:   

2015 Income Guidelines 

Para mas información, por favor llame 209‐468‐0439. 

www.sjchsa.org 

Como inquilino o dueño de casa, usted puede ser elegible para 

Que su hogar o casa móvil reciba servicios de 

Climatización que le ayuda ahorrar dinero  a ningun costo. 

Que es climatización? Es hacer arreglos a un hogar para protejerlo de los rayos del sol, la lluvia, y el viento.  Ayuda a reducir el uso de energía e incrementa la eficiencia de energía. 

 El Programa de  Climatización Provee  estos 

servicios  Gratis para hogares e individuales que 

califican.   Puede incluir: 

Reparación o reemplazo de ventana (vidrio solamente) 

Reparación o reemplazo de la puerta  Refrigerador, micro‐ondas, estufa de gas gratis  Reparación o reemplazo de Calefacción o Aire 

Acondicionado  Insulación  Reparación o reemplazo del Calentador de Agua  Ventilador de techo  Regadera  Detector de Humo  Detector de Monóxido de Carbono  Termóstato Digital  La cinta de aislamiento  La Weather‐stripping 

#

personas

en casa*

Ingreso

Anual

Ingreso

Mensual

1 $23,963 $1,996.89

2 $31,336 $2,611.31

3 $38,709 $3,225.74

4 $46,082 $3,840.17

*Para hogares con mas de 5 personals, llame al 209‐468‐0439 

Baje su cuenta de energía 

Turn page over for English. 

San Joaquin County Human Services Agency Our mission is to lead in the creation and delivery of services that improve the quality of life in our community. 

S A N J O A Q U I N C O U N T Y Weatherization Program

Thank you for your interest in FREE weatherization services from the San Joaquin Weatherization Program. The Weatherization Program provides energy saving measures and repairs to eligible homes in San Joaquin County. The program can weatherize owner-occupied homes and rental properties at no cost, including single family homes, mobile homes, and multi-family units up to a four-plex. To apply for weatherization services, please complete the following forms and return them with your HEAP application and supporting documents:

1. Conditions of Work 2. Energy Service Agreement For Rental Units Form CSD 515 (For Renters Only) 3. Household Facts

Please contact us with any questions at 209-468-0439. San Joaquin County Weatherization Program PO Box 201056 Stockton, CA 95201

S A N J O A Q U I N C O U N T Y

Weatherization Program

DWELLING INFORMATION

Applicant Name:

Address of Dwelling: The home to be weatherized is a:

HOUSE *DUPLEX *3 - 4 PLEX MOBILE HOME *Single level dwellings only. No townhomes, condominiums, or apartments.

Owner Occupied? Yes_____ No_____ If yes, title is recorded in the name of: *NOTE: If this home is currently for sale or in foreclosure, weatherization services cannot be provided. Rented or Leased? Yes_____ No_____ If yes, please provide landlord name, address, and phone number: *NOTE: If you are renting your landlord will need to fill out the Energy Service Agreement Form (attached). Has this dwelling been weatherized before? Yes_____ No_____ If yes, Name of Agency:__________________________________________________(YEAR) _______ Year Built (if known): _________ The exterior siding of the home is: Brick___ Wood___ Stucco___ Aluminum___ Other: __________________ Heat Fuel: Gas___ Propane___ Electric___ Wood___ Cooking: Gas___ Propane___ Electric___ Heating Type: Central Heat___ Window/Wall___ Portable Device___ None___ Other:___________________ Working? Yes_____ No_____ Water Heater Type: Gas___ Electric___ Working? Yes_____ No_____ Cooling Type: Central AC___ Window/Wall AC___ Fans___ Portable Device___ None___ Other:__________ Working? Yes_____ No_____

MICHAEL MILLER SAN JOAQUIN COUNTY Director

AGING, ADULT AND COMMUNITY SERVICES P.O. Box 201056 102 South San Joaquin Street Stockton, CA 95201-3006

Tel (209) 468 -2202 Fax (209) 468 -2207

CONDITIONS OF WORK The following conditions must be met before any work on your dwelling can begin. Failure to abide by these conditions may be cause for denial of weatherization services.

Client is required to be available by telephone until work/inspection is completed.

Home must be clean.

Home must have suitable access to outside area for trucks and other equipment.

Area around attic access must be removed.

Items stored in attic must be removed.

Roof must not have water leaks.

Yard must be free of debris.

Children must be kept out of equipment and workers’ way.

All dogs must be restrained and kept away from work area at all times.

An adult 18 years old or older must be present at all times while work is being performed.

Clients must allow for mandated inspection of residence.

Agency is not responsible for any damages to personal items in normal course of work if the above requirements are not met.

I agree to the above stated conditions and understand that weatherization of my home may not be completed if these conditions are not met.

______________________________ Print Client Name Client Signature Date ______________________________ ______________________________ Print Client Address Assessor’s Signature Date

State of California

DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT

CSD 515 (Rev. 11/12/09)

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Dwelling Information

Apt./Unit No. City

The tenant authorizes the contractor access to utility company records to obtain only energy usage data for a period

of one year before and one year after rehabilitation, minor home repair, and/or weatherization measures are installed.

ZIP Code

Tenant and Owner Authorization

DateTenant’s Signature

Apt./Unit No.

Tenant (Print or type name) Address

If the Owner uses an agent for the above-referenced property, complete both Owner and Agent information.

Agent (Print or type name)

Owner (Print or type name) Address

Tenant telephone numberCity ZIP Code

Apt./Unit No. City ZIP Code Owner telephone number

By signing this form, the owner or owner's agent and the tenant grant the contractor permission to enter the dwelling unit

to perform an assessment and install feasible weatherization measures in accordance with CSD weatherization program

policies and standards to the above-described unit and agree to the following:

The owner or owner's agent and the tenant shall retain all applied measures in the residence where installed.

The owner or owner's agent shall ensure that gas or electric service, or both, that is provided by a master-meter to

tenants shall charge utilities costs in accordance with California Public Utilities Commission Code Section 739.5.

Owner’s (or Owner's Agent’s) Signature Date

Agent telephone number

ENERGY SERVICE AGREEMENT FOR OCCUPIED/UNOCCUPIED

SINGLE OR MULTI-UNIT RENTAL UNITS

The owner or owner's agent shall not raise the rent of the unit for a period of two years or evict the unit's resident

because of the increased value of the unit due solely to weatherization measures provided by the Contractor

(allowable factors include an actual increase in property taxes, actual cost of amortizing other improvements to the

Address

Single-Family

Failure of the Contractor to enforce this Agreement upon breach by the Owner shall not be construed as a waiver of

the Contractor's right to enforce this Agreement.

No. of Multi-Family

Units# of Vacant UnitsMulti-Family

If Rental is an UNOCCUPIED MULTI-UNIT Dwelling, please complete page on back . OVER ------->

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7. I authorize (Contractor)

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I certify that I am the Owner/Authorized Agent (Owner/Agent) for the property located at:

Owner Certification ONLY if Unoccupied Multi-Unit Dwellings

Contractor Assurance

Contractor (Print or type name) Address

I hereby release and pledge to hold harmless the above-named Contractor, and its staff, from any

liability in connection with the work listed above.

Program Manager’s Signature Date

Shall schedule weatherization services at the convenience of all parties.

Shall provide weatherization services only to eligible rental units or to unoccupied multi-unit buildings that will

become eligible within 180 days under program requirements.

Shall provide in writing all weatherization measures installed in the unit.

Shall assure that the owner, or owner's agent, and tenant data shall be maintained in a confidential manner to assure

compliance with the Information Practices Act of 1977, as amended, and the Federal Privacy Act of 1974, as

amended.

Shall not make any significant structural changes to the dwelling without requesting written permission specifically

describing the change from the dwelling owner.

Room No. City ZIP Code Contractor telephone numberStockton

Shall ensure that the Contractor is insured and shall be responsible for damage to unit premises, furnishing, and/or

resident(s) that is caused by weatherization activities.

I agree that "rent" is defined as the tenant's monthly payment to the Owner (non-subsidized housing) or the contract

rent (subsidized housing).

95201 209-468-0439

I certify that I shall provide a copy of this Agreement and a synopsis explaining its terms to all tenants and

subsequent tenants residing in the unit within the two year period. This synopsis shall include the complaint

procedure and current telephone number of the Contractor should the provisions of this Agreement not be met.

Shall be responsible for the feasible cost of weatherization measures performed other than cash contribution from the

Owner’s (or Owner's Agent’s) Signature Date

The contractor agrees to the following:

San Joaquin County Department of Aging & Community SrvcsP O Box 201056

to make the following minor home repair and/or weatherization measures and improvements at the above-referenced

property, depending upon feasibility, cost effectiveness, and/or other factors.

Should any of the agreements contained in this document not be met or are found to be out of compliance with the

above stated program, the above named Owner or Agent shall be financially responsible for the entire amount of

weatherization work performed on the non-compliant units at the above address and will remit this amount to the

above named Contractor immediately.

I certify I will rent to low-income tenants that meet the income qualifications for the Department of Energy

Weatherization Assistance Program or Low-Income Home Energy Assistance Program within 180 days of work

completion.

I shall submit to the Contractor a schedule of rents prior to commencement of work.

I certify that rents shown on this schedule shall not increase for a period of two years beginning the day an eligible

tenant moves in unless the rent increase is based on factors other than the increased value of the unit due to the work

performed by the Contractor (allowable factors include an actual increase in property taxes, actual cost of amortizing

other improvements to the property accomplished after the date of work completed by the Contractor, or actual

increases in expenses of maintaining and operating this property).