STEP 3: SUBMIT FOR *PROCESSING

BY DROP BOX

SJC Human Services Agency

HEAP Self-Service Drop Box

333 E. Washington Street

Stockton, CA 95202

*BY MAIL

Energy Program

PO Box 201056

Stockton, CA 95201

*Postage paid envelopes available.

STEP 2: ATTACH SUPPORTING DOCUMENTS

TOTAL GROSS INCOME

For ALL household members

Adults with zero income? Include form CSD 43B filled out and signed by each household member 18+ with no income

Zero HOUSEHOLD income? CSD 43B + Statement of Financial Support (filled out by Applicant) to explain how monthly living expenses were paid

US CITIZENSHIP

For Applicant Only

Birth Certificate

Certificate of Naturalization

Permanent Resident Card (Green Card)

ENERGY BILL

All Pages of the Regular Bill

*Shut-Off? Include PG&E Account Information Sheet -or- Notice for City of Lodi and Modesto Irrigation in addition to the regular bill *Required for emergency assistance.

(See Document Checklist on the back page for a list of acceptable documents)

STEP 1: FILL OUT AND SIGN APPLICATION FORMS

HEAP (Utility Bill Assistance)

Energy Intake Form

Statement of Citizenship

Acknowledgment Form

Customer Consent Form

PG&E Cares Application (Optional)

WEATHERIZATION (Home Repair)

HEAP Forms + Weatherization Forms

*ADDITIONAL FORMS

Certification of Income and Expenses (CSD Form 43B)

Statement of Financial Support *As applicable. Additional forms not included with application. Forms available in the HSA lobby or on the website.

QUESTIONS? PHONE

209-468-3988

WEBSITE

www.sjchsa.org

OFFICE HOURS

8AM to 5PM

PHONE HOURS

9AM to 12PM and 1PM to 4PM

HOW TO APPLY FOR LiHEAP

All documents must be current within 30 days of application date.

*Please allow 4 to 6 weeks for processing.

PASO 3: ENVIAR PARA PROCESAMIENTO

BUZON DE HEAP

SJC Human Services Agency

(HEAP Self-Service Drop Box)

333 E. Washington Street

Stockton, CA 95202

*POR CORREO -O-

Programa de Energía

PO Box 201056

Stockton, CA 95201

*Sobre Pre-Pagado Disponible

PASO 2: INCLUIR DOCUMENTOS DE APOYO

TOTAL DE INGRESES EN BRUTO

Para TODOS los miembros del hogar

Adultos sin ingresos? Incluya la forma CSD 43B llenada y firmada por cada miembro del hogar 18+ sin ingresos

Hogar con CERO ingresos? CSD 43B + Declaracion de Apoyo Financiero (llenado por el solicitante) Para explicar como cada mes se pagan los gastos

CIUDADANIA ESTADOUNIDENSE

Para Solicitante Solamente

Acta de Nacimiento E.U.

Certificado de Naturalización

Tarjeta de Residente Permanente (Mica)

FACTURA DE ENERGÍA

Todas las Paginas de la factura

*Desconectado? Incluya Hoja de Informacion de Cuenta de PG&E o Aviso de la Cuidad de Lodi o de Irrigación de Modesto, ademas la cuenta normal. *Requisito para asistencia de emergencia

(Vea Lista de Comprobacion de Documentos en la Ultima Pagina, Para Una Lista de Documentos Aceptable)

PASO 1: LLENAR Y FIRMAR LOS FORMULARIOS DE SOLICITUD

HEAP (Asistencia Para Pagar Servicios

Publicos)

La Forma de Consumo de Energía

Declaración de la Ciudadania

La Forma de Reconocimiento

El Formulario de Consentimiento de Cliente

Solicitud de PG&E Cares (opcional)

CLIMATIZACIÓN (Reparación de Hogar)

Formas HEAP + Formas de Climatización

*FORMAS ADICIONALES

Certificación de Ingresos y Gastos (Forma CSD 43B)

Declaración de Apoyo Financiero *Segun sea aplicable. Formularios adicionales no incluidos con la aplicación estan disponi-bles en el vestibulo de HSA o en sitio web

Preguntas? Telefono

209-468-3988

Sitio Web

www.sjchsa.org

HORAS DE OFICINA

8AM to 5PM

HORAS DE TELEFONO

9AM to 12PM y 1PM to 4PM

     

Como Solicitar LiHEAP

San Joaquin County Human Services Agency

LOW INCOME HOME ENERGY ASSISTANCE PROGRAM 2016 (LIHEAP)

ACKNOWLEDGMENT FORM

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.

2016 Income Guidelines at 60% of State Median Income (SMI)

1 2 3 4 5 6 7 8 9 10

2,004.77 2,621.63 3,238.48 3,855.33 4,472.19 5,089.04 5,204.70 5,320.36 5,436.02 5,551.68

Applicant Responsibilities: 1. Submit 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. Submit supporting documentation for ALL of the following (SEE DOCUMENATION

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

5. Keep the Assurance 16 Home Energy Conservation and Home Budgeting Fact Sheets for your records. 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 costs 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

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: SJC Aging & Community Services 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 $

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 Fuel List 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 Fuel In addition to your main heating source, do you ever use any of the following to heat your home (you can select more than one): (Attach copy of most recent bill or receipt) ☐ Natural Gas ☐ Electricity ☐ Wood ☐ Propane ☐ Fuel Oil ☐ Kerosene ☐ Other Fuel ☐ N/A Energy 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 ☐ No 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 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 weatherized Energy 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

Nombre Inicial Apellido Fecha de Nacimiento

MM/DD/YY

Domicilio Postal Número de Unidad

Ciudad (de su domicilio postal) Condado Estado Código Postal

Domicilio De Servicio-Domicilio donde vive el aplicante (No use Apartado Postal - P.O. Box)

Es igual que la domicilio postal?....................................................................................................................................................... ☐ Sí ☐ No

Han vivido en esta residencia durante cada uno de los últimos 12 meses …………………………………………………………………………………. ☐ Sí ☐ No Domicilio de servicio Número de Unidad

Ciudad Condado Estado Código Postal

Número de Seguro Social (SSN): Número de Teléfono: ( ) ☐Mensaje Only?

Correo electrónico (opcional):

MIEMBROS DEL HOGAR (Opcional) NOMBRE COMPLETO: Su nombre completo es Nombre, Apellido. RELACIÓN CON EL SOLICITANTE: POR ejemplo: marido, hija, amiga, tía, abuelo, etc. FECHA DE NACIMIENTO: ANOTE la fecha de nacimiento de cada miembro del hogar. CANTIDAD DE INGRESO MENSUAL EN BRUTO: “bruto” ingreso significa la cantidad de dinero recibido antes de impuestos o cualquier otra deducción. Si usted tiene más de 8 personas en su hogar, usted puede escribir la información en una hoja de papel separado.

Nombre Apellido Parentesco con el Solicitante

Fecha de Nacimiento MM/DD/AA

Cantidad de ingreso mensual

Fuente de ingreso

sí mismo

Total de Ingresos Mensuales en Bruto $

¿Usted o alguien en su casa ACTUALMENTE recibe CalFresh (estampillas de comida)? ☐ Sí ☐ No

Department of Community Services and Development Official Use Only:

Energy Intake Form Priority Points

CSD 43 (11/2015) A.C.C.

Agency: SJC Aging & Community Services Intake Initials: Intake Date: Eligibility Cert Date

Job Control Code

PERSONAS VIVIENDO EN EL HOGAR Escriba el número de

personas que viven en

su hogar , incluyendo al solicitante

INGRESOS Escriba el número de personas en el

hogar que reciben ingresos

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

De 2 años o menores TANF $

De 3 años a 5 años SSI / SSP $

De 6 años a 18 años SSA / SSDI $

De 19 años a 59 años Sueldo(s) $

De 60 años o mayores Interés $

Incapacitados Pensión $

Americanos Nativos Otros Ingresos $

Campesinos Temporales/Migratorios Ingresos Total $

¿A cual factura de energía desea aplicar su beneficio de LIHEAP? (Adjuntar Copia de la Factura o Recibos) ☐ Gas Natural ☐ Electricidad ☐ Madera ☐ Propano ☐ Aceite Combustible ☐ Queroseno ☐ Otro combustible Lista compañía de energía y número de cuenta: Nombre de la compañía: _____________________ Número de cuenta: ____________________

¿Cuál es el principal combustible que se utiliza para CALENTAR su casa? Una fuente principal de calefacción DEBE estar marcada (Adjuntar Copia de

la Factura o Recibos)

☐ Gas Natural ☐ Electricidad ☐ Madera ☐ Propano ☐ Aceite Combustible ☐ Queroseno ☐ Otro combustible Además de su fuente principal de calefacción, alguna vez utiliza cualquiera de los siguientes para calentar su casa (usted puede seleccionar más de uno): (Adjuntar Copia de la Factura o Recibos)

☐ Gas Natural ☐ Electricidad ☐ Madera ☐ Propano ☐ Aceite Combustible ☐ Queroseno ☐ Otro combustible ☐ N/A

Información de su factura de Energía Marque todas las que apliquen para cada tipo de fuente de energía para los gastos de energía del hogar. NOTA: Las preguntas siguientes son OBLIGATORIOS y requieren una respuesta Incluya copias de sus facturas más recientes de energía Y/O recibos (si es aplicable) y adjuntar a esta solicitud

SERVICIO ELÉCTRICO

¿Son sus utilidades todo eléctrico? _

☐ Sí ☐ No

¿Está apagada su electricidad?

☐ Sí ☐ No

¿Tiene actualmente un aviso de pago atrasado?

☐ Sí ☐ No

SERVICIO DE GAS NATURAL

¿Su Compañía de Electricidad el mismo que su Compañía de Gas Natural?

☐ Sí ☐ No _ __ __

¿Está apagado su Gas Natural?

☐Sí ☐ No ¿Tiene actualmente un aviso de pago atrasado?

☐Sí ☐ No

MADERA, PROPANO or SERVICIO DE ACEITE CUMBUSTIBLE (WPO)

¿Está usted actualmente sin combustible? (Madera, Propano, Aceite, queroseno, Otro Combustible) ☐ Sí ☐ No ☐ N/A

Anote el número aproximado de días hasta que te quedas sin combustible (Madera, Propano, Aceite, queroseno, Otro Combustible).

Número de días: _____________ ☐ N/A

¿Está su electricidad incluida en la renta o sub-medidos? ☐ Sí ☐ No

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 este consentimiento permanecerá en vigor durante tres años a partir de la fecha de la firma, a menos que sea revocada por mí por escrito. 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.

X

* * * FIRMA DEL SOLICITANTE * * * Fecha de hoy 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 reúne 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 actualización 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 elegibilidad. 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.

SOLICITANTE: NO COMPLETE LA SIGUIENTE INFORMACIÓN. ESTA SECCIÓN ES SÓLO PARA USO OFICIAL.

Utility Assistance being provided under which program ☐ HEAP ☐ Fast Track ☐ HEAP WPO ☐ ECIP WPO

Supplement $________________ Total Benefit $_______________ ☐ Home referred for WX ☐ Home already weatherized

Energy 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

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

CSD Form 081 (NEW 5-15) Page 1 of 2

CLIENT/CUSTOMER CONSENT FORM AND AUTHORIZATION

The California Department of Community Services and Development (CSD) is a state

agency that oversees energy assistance programs for low-income families. Some of

these services include helping families pay their utility bills or installing energy-efficient

appliances and systems to reduce energy use and expenses. CSD also works with other

organizations and programs that provide related services.

CONSENT (What you are agreeing to when you sign this form) By signing this form, you give your consent (permission) to CSD, its contractors, consultants, other federal or state agencies

(CSD Partners) and to your utility company and its contractors, to share information about your household’s utility account,

energy usage and/or other information needed to provide the services and benefits to you described on the back of this form.

1. NAME(S) AND MAILING ADDRESS Your Name If your utility bill is in someone else’s name, enter that name here Your mailing address (Street)

Unit Number (if any)

Your mailing address (City)

State

Zip Code

2. UTILITY SERVICE ADDRESS Check here if your utility service address is different from your mailing address. If you checked the box, please provide your utility service address information below:

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

Your Utility Service Address (City)

State

CA Zip Code

3. UTILITY INFORMATION Please enter your utility company name and service account number below (you can find the account number on your bill). If different companies provide your electricity and gas services, please enter the name and account number for both utilities.

Name of Utility Company

Service Account Number

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

Service Account Number

AUTHORIZATION (If client applying for services is not the person whose name is on the account (i.e., the utility customer of record), both persons must initial and sign this form)

By initialing and signing below, I acknowledge and authorize my utility company, CSD, and CSD Partners to release upon

request and/or to receive my information as described, exclusively for the purposes stated in this Authorization for up to 36

months unless revoked as explained on the back of this form:

Client/Customer Initials Utility company billing records: account name, service address, billing history and account balances, as needed for processing utility bill assistance and emergency payments.

Client/Customer Initials 1) Meter usage and energy consumption data, including up to 12 months of historical data prior to the date of my signature below; and 2) any information concerning prior weatherization of dwelling (if weatherized, date and measures installed).

Client/Customer Initials Household income, composition and other information needed to determine my eligibility for energy assistance programs administered by CSD and/or CSD Partners.

Signature of Client/Utility Customer Date Signature of Utility Customer of Record (if different) Date

Name of CSD Contractor/Partner Organization Signature of 2nd Utility Customer of Record, if applicable Date

CSD Form 081 (NEW 5-15) Page 2 of 2

WHY CONSENT IS NEEDED AND HOW THE INFORMATION WILL BE USED

Your consent (permission) for us to obtain and share your utility information, including your energy usage data, is

needed for the purposes listed and explained below. CSD, its contractors, consultants, other federal or state

agencies and affiliated programs (CSD Partners), working cooperatively with your utility company and its

contractors, can provide you with services and benefits available under various programs administered by CSD and

your utility companies. The information provided will be shared and retained in accordance with applicable law

concerning data security and privacy protections. The information you authorize us to obtain and share will be

used for the following purposes:

1. Determine your eligibility for CSD and utility company low-income programs

2. Protect the security of your information and make it easier for you to apply for/receive services by limiting

the number of times you must provide the same information about yourself and your household, your

residence, income, utility account(s), energy costs and energy usage

3. Determine which services, benefits and assistance you are qualified to receive, including: payment

assistance with your utility bills; weatherization services; energy efficiency services; emergency energy

services; health and safety measures; solar energy services; consumer information and energy tips

4. Evaluate your home’s energy usage so that CSD can: a) measure the effectiveness of the services we

provide by determining how much your utility bills are reduced and how much our services reduce carbon

emissions (air pollution), and b) report these results to federal and state authorities that fund and oversee

energy assistance programs in California.

You understand that some services may not be available to you unless you consent to share/release information as

stated in this Authorization. You agree that this consent covers utility account, billing and usage information,

including up to twelve months of historical data prior to the date of this Authorization, information about any prior

weatherization services provided, and subsequent data throughout the period that this Authorization is in effect.

CSD and CSD Partners agree to access and share only the information and data necessary to provide energy

assistance services for which you are determined eligible, and to fulfill state and federal requirements for operating

these programs. If you are determined not to be eligible for services, no utility information will be accessed or

exchanged. CSD and CSD Partners will safeguard your privacy and will store any information gathered in

accordance with the security requirements set forth in state law.

REVOCATION OF CONSENT

You agree that your consent shall remain in effect for 36 months from the date you sign this Authorization, unless

otherwise revoked by written notice mailed to: CSD Energy & Environmental Services Division, 2389 Gateway

Oaks Drive, Suite 100, Sacramento, CA 95833. Revocation will be effective upon receipt, but will not apply to any

information shared while this Authorization was valid.

PROGRAMS

Some of the programs CSD oversees or partners with include:

- CSD Federal Low-Income Home Energy Assistance Program (LIHEAP)

- CSD Federal Department of Energy Weatherization Assistance Program (DOE WAP)

- State Low-Income Weatherization Program (LIWP)

- Department of Housing and Urban Development (HUD) Lead Hazard Control and Healthy Homes Program

- Utility Company Energy Savings Assistance (ESA) Program

- Utility Company California Alternate Rates for Energy (CARE) Program

CSD Formulario 081 (NUEVO 5-15) Página 1 de 2

FORMULARIO DE CONSENTIMIENTO Y AUTORIZACIÓN DEL CLIENTE/CONSUMIDOR

El Departamento de Servicios Comunitarios y Desarrollo de California (CSD) es una oficina

estatal que supervisa los programas de asistencia energética para familias de bajos ingresos.

Algunos de los servicios que ofrece consisten en ayudar a las familias a pagar sus facturas de

servicios públicos o en instalar electrodomésticos, artefactos y sistemas de bajo consumo para

reducir el consumo de energía y los gastos que este ocasiona. A su vez, el CSD trabaja en

conjunto con otras organizaciones y otros programas que ofrecen servicios afines.

CONSENTIMIENTO (Lo que acepta al firmar este formulario) Al firmar este formulario, usted presta su consentimiento (autorización) para que tanto el CSD, sus agentes, asesores, otras agencias federales y estatales (Asociados de CSD), como la empresa proveedora de servicios públicos y sus agentes, compartan información sobre las cuentas de servicios de su hogar, el consumo de energía, o cualquier otra información necesaria para otorgarle los servicios y beneficios que se describen en el reverso de este formulario.

1. NOMBRE(S) Y DIRECCIÓN POSTAL Su nombre Si el nombre en su factura es diferente, escriba el nombre aquí. Su dirección postal (Calle)

Número de unidad Si corresponde

Su dirección postal (Ciudad)

Estado

Código Postal

2. DIRECCIÓN DONDE RECIBE LOS SERVICIOS Marque este casillero si la dirección donde recibe los servicios difiere de la dirección postal. Si marcó el casillero, por favor proporcione la dirección donde recibe los servicios en el siguiente cuadro:

Dirección donde recibe los servicios (Calle) Número de unidad Si corresponde

Dirección donde recibe los servicios (Ciudad)

Estado

CA Código Postal

3. INFORMACIÓN DE LOS SERVICIOS PÚBLICOS Por favor proporcione el nombre de la empresa que le provee los servicios públicos y su número de cuenta en el siguiente cuadro (puede encontrar este número en su factura ). Si el servicio de gas y electricidad no es administrado por la misma empresa, escriba el nombre de la empresa y el número de cuenta correspondiente para cada servicio:

Proveedor de servicios públicos

Número de cuenta

Proveedor de servicios públicos (si tiene más de uno)

Número de cuenta

AUTORIZACIÓN (Si el cliente que firma la solicitud no es la persona que figura como titular de la cuenta en los registros, ambos deberán incluir sus iniciales y firmar el formulario)

Entiendo que al inicialar y firmar este formulario autorizo a mi proveedor de servicios públicos, al CSD y a sus asociados a liberar mi información cuando así se solicita o recibirla según se detalla, por un período de 36 meses y exclusivamente a los efectos listados en esta autorización, a menos que se revocara esta autorización según lo dispuesto en el reverso de este formulario:

Iniciales del Cliente Historial de facturación de la empresa de servicios públicos: titular de la cuenta, dirección del servicio, antecedentes de facturación y saldos de la cuenta según se requiera para el procesamiento de pagos de emergencia y asistencia para el pago de la factura de servicios públicos.

Iniciales del Cliente 1) Datos registrados en el medidor y datos sobre el consumo de energía, incluyendo la información correspondiente a los 12 meses previos a la fecha de mi firma de este formulario; y 2) toda la información relacionada con la protección de la vivienda contra las inclemencias del tiempo (si la vivienda estuviera protegida, indicar la fecha y las medidas implementadas).

Iniciales del Cliente Ingresos familiares, composición familiar y cualquier otra información necesaria para determinar mi derecho a recibir asistencia energética a través de los programas del CSD o sus Asociados.

Firma del cliente/Titular del servicio Fecha Nombre del agente del CSD/Organización Asociada

Fecha

Firma del cliente en la factura de servicios (si fuera distinto del que

completa la solicitud)

Firma del agente del CSD/Organización Representante

Fecha

CSD Formulario 081 (NUEVO 5-15) Página 2 de 2

POR QUÉ NECESITAMOS SU CONSENTIMIENTO Y CÓMO SE UTILIZARÁ SU INFORMACIÓN

Es necesario que preste su consentimiento (autorización) para que obtengamos y liberemos la información relacionada

con sus servicios públicos, incluida la información relacionada a su consumo de energía, por las razones que se indican a

continuación. El CSD, sus agentes, asesores, otras oficinas federales y estatales y los programas asociados (Asociados

del CSD), trabajan junto con su empresa de servicios públicos y los agentes de ésta para ofrecerle los servicios y

beneficios que brindan varios de los programas administrados por el CSD y su empresa de servicios públicos. La

información suministrada se conservará y se liberará de conformidad con las leyes sobre privacidad y protección de datos.

Utilizaremos la información que nos autorice a obtener y compartir con los siguientes propósitos:

1. Determinar si reúne los requisitos para acceder a los programas para familias de bajos ingresos que ofrecen el

CSD y los proveedores de servicios públicos.

2. Resguardar la seguridad de su información y facilitar el proceso de solicitud/otorgamiento de servicios al restringir

la cantidad de veces en las que tiene que brindar la misma información acerca de usted y su hogar, su residencia,

sus ingresos, su(s) cuenta(s) de servicios públicos, sus gastos por consumo de energía y datos sobre el consumo

de energía en su hogar.

3. Determinar qué servicios, beneficios y tipo de asistencia tiene derecho a recibir, incluyendo: asistencia económica

en el pago de sus facturas de servicios públicos; servicios de protección de la vivienda contra las inclemencias del

tiempo; servicios de aprovechamiento de energía eléctrica; servicios de energía de emergencia; medidas de

seguridad y salud; servicios de energía solar; información para el consumidor y sugerencias para el consumo de

energía.

4. Evaluar el consumo de energía en su hogar, de modo que el CSD pueda: a) determinar la reducción en el monto

de las facturas de servicios públicos y la medida en que nuestros servicios logran reducir las emisiones de

carbono (contaminación atmosférica), lo que nos permitirá medir la eficacia de los servicios que brindamos, y b)

reportar estos resultados a las autoridades federales y estatales que financian y supervisan los programas de

asistencia energética en California.

Usted entiende que es posible que algunos servicios no estén disponibles para usted a menos que preste su

consentimiento para compartir/liberar cierta información según se detalla en esta Autorización. Entiende que el

consentimiento que presta abarcará su cuenta de servicios públicos, información de facturación y de consumo de los

últimos 12 meses, información sobre servicios de protección de la vivienda contra las inclemencias del clima que hubiera

contratado en el pasado, así como información nueva que surja durante el período de vigencia de esta Autorización.

El CSD y sus Asociados se comprometen a acceder y compartir sólo la información y los datos necesarios para ofrecer

servicios de asistencia energética a los clientes elegibles y a cumplir con las disposiciones federales y estatales que

regulan la puesta en marcha de estos programas. Si se determina que usted no reúne los requisitos para recibir nuestros

servicios, no compartiremos ni accederemos a la información relacionada con sus servicios públicos. El CSD y sus

Asociados protegerán su privacidad y conservarán toda la información recopilada de conformidad con los requisitos

establecidos en las leyes estatales.

REVOCACIÓN DEL CONSENTIMIENTO

Por medio de la presente, declaro estar de acuerdo con que el período de vigencia de esta autorización sea de 36 meses

corridos desde la fecha de su suscripción, salvo que revoque mi consentimiento por escrito y envíe la documentación a tal

efecto por correo a: CSD Energy & Environmental Services Division, 2389 Gateway Oaks Drive, Suite 100, Sacramento,

CA 95833. La revocación será efectiva a partir de su recepción por parte del CSD pero no afectará la información que se

haya compartido durante el período de vigencia de esta autorización.

PROGRAMAS

A continuación se detallan algunos de los programas que el CSD supervisa o a los que está asociado:

- Programa Federal de Asistencia para Energía para Hogares de Bajos Recursos (LIHEAP)

- Programa de Asistencia de Climatización del Departamento de Energía de los Estados Unidos (DOE WAP)

- Programa Estatal de Climatización para Hogares de Bajos Ingresos (LIWP)

- Programa de Hogares Saludables y Control de Peligros del Departamento de Vivienda y Desarrollo Urbano (HUD)

- Asistencia para el Ahorro de Energía (ESA)

- Programa de Tarifas Alternativas para Energía de California (CARE)

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Typewritten Text

234

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 $24,057 $2,004.77

2 $31,459 $2,621.63

3 $38,861 $3,238.48

4 $46,263 $3,855.33

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 4 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 gratuitos de 

Climatización que le ayudara ahorrar dinero. 

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 individu0s que califiquen. 

   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 (Weather‐stripping) 

#

personas

en casa*

Ingreso

Anual

Ingreso

Mensual

1 $24,057 $2,004.77

2 $31,459 $2,621.63

3 $38,861 $3,238.48

4 $46,263 $3,855.33

*Para hogares con mas de 4 personas, llame al 209‐468‐0439 

Reduzca 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

DWELLING INFORMATION

Applicant Name:

Applicant Phone Number (s): Home: Mobile/Cell:

Address of Dwelling:

No. People in Household:

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_____

FOR STAFF USE ONLY:

Intake Date:

ST Job#:

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 CaliforniaDEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENTCSD 515 (Rev. 11/12/09)

1.

2.3.

4.

5.

1.

2.

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

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.

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

Address

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

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

Owner (Print or type name) Address

Tenant telephone numberCity 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)

Dwelling Information

Owner Certification ONLY if Unoccupied Multi-Unit Dwellings

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 Agent telephone number

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

3.

4.7.

5.

6.

7. I authorize (Contractor)

8.

1.

2.

3.4.

5.

6.7.

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 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).

Shall be responsible for the feasible cost of weatherization measures performed other than cash contribution from the Owner or Owner Agent, and any subsequent non-compliance.

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

The contractor agrees to the following:

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.

San Joaquin County Human Services Agency 102 S. San Joaquin Street, P O Box 201056

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.

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.

Contractor AssuranceContractor (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.

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

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RE

AC

H is a one-tim

e energy-assistance program sponsored by P

G&

E and adm

inistered through the S

alvation Arm

y from 170 offices in northern and central C

alifornia.

Stockton | 209-948-8955 Lodi | 209-369-5896

Tracy | 209-836-2346

California P

ublic Utilities C

omm

ission (CP

UC

) | 1-800-649-7570 If your energy, telephone, or w

ater has been shut off because you fell behind on your bills, the C

PU

C m

ay be able to help you get your services restarted.

* * * CO

MM

UN

ITY

CO

NN

EC

TIO

NS

* * *

INF

OR

MA

TIO

N A

ND

AS

SIS

TA

NC

E

S

an Joaquin County A

ging and Com

munity S

ervices Inform

ation and Assistance P

rogram

209-468-1104 | 1-800-510-2020

Com

munity A

ction Centers (C

AC

’s)

For over tw

enty-five years, the San Joaquin C

omm

unity Centers have been provid-

ing a wide variety of direct and referral services to individuals and fam

ilies through a netw

ork of eight (8) comm

unity centers. Center staff provides linkage and refer-

rals to agencies to assist individuals and families in the areas of hum

an services, em

ployment, health, nutrition, housing assistance and education 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 W

ay Stockton, CA

 95205  

(209) 468‐3918

 

Ta Center 

389 W

. Downing Avenue

 

Stockton, CA 95206

 

(209) 468‐4168

 

Thornton Center 

26675 N. Sacram

ento Blvd

 

Thornton, CA 95686

 

(209) 794‐2144

 

 S

AN

JOA

QU

IN C

OU

NT

Y H

OM

E E

NE

RG

Y A

SS

IST

AN

CE

PR

OG

RA

M

209.468.3988 1.877.977.3988 | 209.932.2649 fax | ww

w.sjchsa.org

F R

E Q

U E

N T

L Y A

S K

E D

Q U

E S

T I O

N S

Q

: Must the utility bill be in m

y name to apply for help?

A: N

o, however the applicant m

ust reside at the service address and be responsible for energy costs in the hom

e. Q

: How

long will it take to process m

y application? A

: Please allow

4 to 6 weeks for processing. T

here is no need to call the office. If your application is approved, a benefit paym

ent will be issued di-

rectly to your utility company in one to tw

o billing cycles after approval. Q

: How

much do I qualify for?

A: T

he benefit amount is based on several factors: the num

ber of people living in the household, the total household incom

e, and energy account status. N

on-emergency benefits range from

$190 to $330. Q

: I have a 48 hour notice, or my utility account is shut-off. W

hat should I do? A

: Call the office M

onday through Friday betw

een the hours of 9:00AM

and 12:00P

M and 1:00P

M and 4:00P

M for crisis instructions. T

he Energy

Crisis Intervention P

rogram offers im

mediate assistance through w

eekly E

nergy Education C

lasses, or through the office depending on the sea-son. IM

PO

RT

AN

T: P

hone lines are extremely busy. If you are unable to m

ake contact w

ith the office, continue to pay your utility bill, or make paym

ent arrangem

ents to avoid service disconnection, or to restore services.

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

Con

side

r th

ese

ener

gy s

avin

g tip

s to

hel

p lo

wer

mon

thly

ene

rgy

cost

s.

San

Joa

quin

Cou

nty

LIH

EA

P |

PO

Box

201

056,

Sto

ckto

n C

A 9

5201

| 20

9-46

8-39

88 |

1-87

7-97

7-39

88 |

ww

w.s

jchs

a.or

g

Budget B

ox System

T

he budget box is a small box w

ith dividers for each day of the month, w

ith one divider for each day of the m

onth.

W

hen you receive a bill, check the due date and place it behind the divider that represents the bill’s due date.

A

s you receive income, pay all bills that are due.

C

omputer S

ystem

If

you have

access to

a personal

computer,

you can

create your

own

spreadsheet (like the one pictured to the right). You m

ay also find free budgeting tools on the internet. C

AU

TIO

N: O

nly visit reputable sites,

Y

ou m

ay also

want

to purchase

a personal

finance program

. T

hey are

available for less than $75.

U

sing a computer to m

anage your finances is relatively simple. O

nce you set up the system

, updating information is quick and easy. It is im

portant to enter transactions frequently to truly understand your financial position.

Envelope S

ystem

T

his tool is useful if you pay your bills in cash each month.

M

ake an envelope for each expense category, such as rent, gas, electricity, and food.

Label the envelope w

ith the name of the category, the am

ount, and the due date.

W

hen you receive income, divide it into the am

ounts to cover the expenses listed on the envelope.

P

ay bills

right aw

ay so

you w

ill not

be tem

pted to

spend the

money

on som

ething else.

For these and other resources, visit

ww

w.m

ymoney.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, prioritize, and m

anage your income and expenses.

Review

your budget often and update it when you are experiencin

g a change in income and expenses. C

onsider these helpful tools:

Sam

ple Household B

udget (P

LEA

SE

KE

EP

FO

R Y

OU

R R

EC

OR

DS

)

    

    

  

Income

Wages

$_________

Public A

ssistance

$_________

S

SA

/SS

I

$_________

P

ension

$_________

O

ther

$_________

Total Incom

e

$________

F

ixed Expenses

R

ent/House P

ayment

$_________

Insurance (Life/Auto/

Hom

e)

$_________

S

avings

$_________

C

redit/Loans/Other

$_________

Total

$________

F

lexible Expenses

U

tilities (Electric/G

as/W

ater)

$_________

F

ood

$_________

H

ealth/Medical

$_________

Phone/C

ell

$_________

C

able TV

/Internet

$_________

T

ransportation/Gas

$_________

Other

$_________

Total

$________

Total E

xpenses

$________

Total Incom

e Minus

Total E

xpenses Equals:

Cash F

low

    

$________ 

San Joaquin C

ounty LIHE

AP

| PO

Box 201056, S

tockton CA

95201 | 209-468-3988 | 1-877-977-3988 | ww

w.sjchsa.org

DOCUMENT CHECKLIST All documentation must be submitted before your application can be reviewed. Check off the documents attached with your application below.

Please send copies. Originals documents will not be returned.

ALL DOCUMENTS MUST BE CURRENT WITHIN 30 DAYS OF APPLICATION DATE

Energy Bill:

Pacific Gas & Electric, Lodi Electric Utility, Modesto Irrigation District Bills; Sub-metered, Propane Statements. Applicants MUST submit ALL pages of the regular bill. FOR DELINQUENT/OR SHUT-OFFACCOUNTS: PG&E Account Information Sheet for Pacific Gas & Electric;

pink or yellow notice AND regular bill for Lodi Electric Utility; Delinquent and regular bill for Modesto Irrigation.

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

Temporary Assistance for Needy Families (TANF): Passport to Services or Notice of Action. Supplemental Security Income (SSI): Notice of Planned Action or Form 2458; annual award letter, 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; printout from Social Security

Administration Office; Bank Statement showing direct deposit; Pension and Annuities: copy of a current check; verification on letterhead dated within 6 weeks of intake date,

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 or 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: FOR SELF-EMPLOYED ONLY (2014 Federal Tax

Form 1040 valid through April 15, 2016) 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, pick up forms in the lobby, or print online under the FORMS icon @ www.sjchsa.org.

HOUSEHOLDS WITH ZERO TOTAL INCOME: Applicant must fill out and submit Form Statement of Financial Support. Applicants claiming no income must reveal their source(s) of support. Applicant households with zero income or expenses that exceed the income, requires the Program to determine how the household is meeting its current living expenses. Current living expenses include but are not limited to: rent/mortgage, utilities (gas, power, trash, and phone), food, insurance and car payments. Inadequate information on the form is cause for denial of benefits. Contact the office, pick up forms in the lobby, or print online under the FORMS icon @ www.sjchsa.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