LIHEAP WEATHERIZATION AND UTILITY ASSISTANCE PROGRAMS
ONLINE APPLICATION INSTRUCTIONS
(Please read ALL instructions BEFORE
you fill out the application)
You may qualify for utility assistance through the LIHEAP program and also for no-cost Weatherization of your home or rental unit. Eligibility for these programs requires that you first meet the income guidelines Final eligibility is determined only after receipt of the completed application and required documents.
Incomplete or unsigned applications will NOT be processed. Completed applications will be compared with those
of other applicants to determine the greatest need based on the following criteria:
• Household income.
• Number and age of individuals in the household.
• Total monthly energy costs (gas, electricity, wood, propane & oil.) • Frail, elderly and life-threatening (medical proof required) conditions.
Utility assistance is provided ONE TIME per program year. Funding is limited. Not all income-qualified individuals
will be assisted. If an applicant qualifies, the application process, from receipt of application to payment, takes approximately 90 Days.
YOU MUST
CONTINUE TO PAY YOUR BILL DURING APPLICATION REVIEW
To apply for assistance, you must complete the attached application. You may fill the form out online, print, scan and email it to: [email protected]
or you can fill out the form online then print and mail it to: Utility Assistance
Community Action Partnership of Orange County 11870 Monarch Street
Garden Grove, CA 92841
If you do not fill out the form online, print clearly utilizing an ink pen. Do not use a pencil.
CLICK ON THIS LINK TO OPEN APPLICATION FORM:
http://www.capoc.org/services/pdf/ees/eesform.pdf
FORM INSTRUCTIONS BY SECTION---USE THE
TAB
KEY TO MOVE THROUGH EACH SECTIONSECTION ONE: Fill out this section with the EMAIL, NAME, ADDRESS, DATE OF BIRTH, and SOCIAL SECURITY
NUMBER of the person applying. Please also list whether you are an OWNER or RENTER, the DATE LAST ASSISTED, NUMBER OF TIMES ASSISTED, and the LANGUAGE you speak.
SECTION TWO: List ALL people living in the household, INCLUDING YOURSELF. Mark how many are in each age
group or classification.
SECTION THREE: List the number of how many people in the household receive income and enter the GROSS (total
PROOF OF INCOME MUST COVER THE LAST 4 WEEKS FROM APPLICATION DATE AND COVER A FULL MONTH
ACCEPTABLE NOT ACCEPTABLE
• Temporary Assistance for Needy Families (TANF): Notice of Action, computer printout, benefit letter, copy of welfare check. Date if Document must be within 30 Days.
• 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. Award Letter indicating income for current year.
• Social Security: 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. • 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 checks(s), printout from Employment Development Department.
• Child and/or Spousal support: copy of current 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.
• Signed Federal Tax Form 1040 (valid through April 15, 2011): WILL ONLY BE ACCEPTED FOR SELF-EMPLOYED.
• Capital Gains. • Adoption Assistance.
• Foster Grandparents and Senior Companion Programs. • Educational assistance - Student income grants loans – Pell
grants.
• Any Assets Withdrawn from a Bank. • Draw down from Reverse Mortgages. • The Sale of Property (Car or House). • Tax Refunds.
• Gifts. • Loans.
• Lump-Sum Inheritances. • One-Time Insurance Payments. • Compensation for Injury.
• Employer or Union Paid Portion of Health Benefits. • Fringe Employee Benefits.
• Withdrawal from Savings.
• Medical Stickers. Food Stamp with NO dollar amount. • Food or Housing Received in Lieu of Wages.
• Federal Non-case Benefit Programs (Medicare, Medicaid, School Lunches, and Housing Assistance).
• W2 Forms and Medi-Cal cards are not accepted as proof of income.
SECTION FOUR: Utility Company Name Please check the box of the Utility Company bill that you would like paid or
if this is in included in your rent check that box stating this. Then list the ACCOUNT NUMBER for the company that you need assistance with and the NAME OF THE PERSON ON THE BILL for that company.
SECTION FIVE: Check all the services that you are interested in receiving. (See DESCRIPTION OF SERVICES)
SECTION SIX: Include the following information for each(please start the list with the name of the Utility Company
bill you would like PAID): YOU WILL NEED COPIES OF CURRENT GAS AND ELECTRIC BILL SHOWING LAST 4-WEEKS OF USAGE, FROM THE DATE OF THIS APPLICATION. (No opening, closing, or outdated utility bills.)
• Billing Period: •
This includes the starting date and ending date, for example 10/10/12 to 11/16/12. Please note that there must be a minimum of 22 days billed.
New Charges: This is just the current amount and DOES NOT
•
INCLUDE a PAST DUE amount. Your new
charges may not match you TOTAL DUE if there is a Past Due amount. It is important you put only NEW CHARGES in this column.
Total Due: This amount may be different from your NEW CHARGES if there is a Past Due or a Credit on
your account. If your bill has a CREDIT you will NOT QUALIFY for the program.
The next few pages include samples of the different utility company bills and where you can locate the information needed for the application. You will find the information circled in RED.
SECTION SEVEN: THE NAME, AGE, AND INCOME (IF OVER 18 years of age) OF ALL persons living in the household
at the time of application. please also check if they are disabled or not. START THE LIST WITH YOUR NAME. (You
may put friend, renter, or tenant if not related)
First Name Middle Initial Last Name Date of Birth
Month Day Year
Address Social Security Number
City Zip Phone
Owner Renter Date Last Assisted Number of Times Assisted Unit Number Language Spoken People Living in Household Enter the TOTAL number of people living in the household including yourself Income Enter the TOTAL number of household members who receive Income Limited‐English Speaking Seasonal or Migrant Farmworker 2 years old or younger Enter the number of people who are: Ages 3‐5 years Ages 16‐18 years Ages 19‐59 (Adult) Ages 60 or older (Elderly) Disabled Native American Other TOTAL INCOME Enter total GROSS* monthly income from all people living in the household including source: TANF SSI/SSP SSA/SSDI Paycheck (s) Interest Pension PLEASE CHECK WHICH UTILITY BILL WOULD YOU LIKE PAID (CHOOSE ONLY ONE) EDISON SOUTHER CALIFORNIA GAS ANAHEIM UTILITIES SDG&E ACCOUNT NUMBER Name of Customer on Utility Bill: From the Description of Services on the instruction page, please check which services that you are interested in receiving:
Utility Assistance (HEAP) Fast Track Assistance Weatherization Refrigerator ECIP
Please list your CURRENT (last 30 days) Utility Company charges.
If you are seeking Utility Assistance please start with the bill you would like assistance on.
Utility Company Billing Period New Charges Total Due
TO $ Total New Charges COMMUNITY ACTION PARTNERSHIP OF ORANGE COUNTY Weatherization and Utility Assistance Form 2012
CLIENT SIGNATURE: ___________________________________________________
DATE: _________________
Check here if your utilities are included in your rent or sub‐metered TO TO TO List EVERYONE including yourself who currently live in the same dwelling (if no one else, write NONE under your name) All persons living in the house that are 18 years old or older MUST provide proof of income or fill out DECLARATION OF NO INCOME form (attached) Use a separate sheet for additional names. HM FIRST NAME MI LAST NAME AGE RELATION TO ME (IF OVER 18)TYPE OF INCOME PERMANENTLY DISABLED 1 YES NO 2 YES NO 3 YES NO 4 YES NO 5 YES NO 6 YES NO
SECTION ONE
SECTION
TWO
SECTION
THREE
SECTION
FOUR
SECTION FIVE
SECTION SIX
SECTION SEVEN
SECTION EIGHT
Account Number
New Charges
New Charges
Billing Period and number of days
The Gas Company Online Bill
Must Click This Option To Print Online
Account Number Billing Period and number of days Total New Charges Total Due
As a not-for-profit agency, ANAHEIM PUBLIC UTILITIEScontinues to offer residential rates 20 to 40% lower than competing utility providers. Below is a breakdown of the key charges you will see on your bill. To get a true comparison of your cost savings, please remember that this bill typically covers a two-month period and encompasses charges for paramedic service, sewer, trash pick up, street sweeping, water, electric and other services.
1. Customer Information
Yourname, service location, and block number are located here. Your block number refers to a geographic section of the City primarily used to identify areas that may be impacted by rotating blackouts when they are ordered by the agency controlling California ’s electric grid system.
2. Account Information
Customeraccount number is the CUSTOMER ID-LOCATION ID
(xxxxxx-xxxxxx).
Your next meter read date and account identification numbers are located here. Each customer has two types of
account identification numbers. First, there is a CUSTOMER ID that is specific to a person that established the account. The second is a LOCATION ID that is associated with your service address.
3. Meter Reading Summary
Your electric and/or water meter read information for the billing period is located here, including the billing dates of service, number of days in the billing period, meter number, the previous and current meter readings. Total consumption for electric is reflected as kilowatt-hours or kWh (one 100 watt light bulb burning for one hour equals 0.1 kWh,) and water is reflected in hundred cubic feet or HCF. (One HCF equals 748 gallons).
4. Summary of Current Charges Your electric and water charges for the billing period are located here.
Most residential customers will see the following electric charges:
• Customer Charge- base charge for providing a meter and associated services, such as meter reading and customer
services.
5. Yearly Comparison
6. Other Charges
7. Total Charges
Your total charges and balances for the current two month period can be found here.8. Important Information
This section displays important messages from the City of Anaheim . Review this section to learnmore about your account or Anaheim programs.
9. Payment Stub
Find out how much you owe and when payment is due. Remember that bills can be paid by mail, via telephone, through Pay
Use the following check list to make sure you have all the information needed if you are scheduled for an
appointment. If you come to a scheduled appointment without the required documents you will be
rescheduled.
CHECK ALL BOXES THAT APPLY
Current Utility Bills With Billing Periods: Must Have Both Bills Even Though We Are Only Assisting With One. o 1st Current Bill Needing Assistance (If Applicable: Past Due or Disconnect Notice),
o 2nd Bill Original Current Bill Only. o If All Electric: Original, Current Electric Bill
o If Utilities are included in RENT, UTILITY NOTICE from Landlord Valid California Picture ID and Proof of Birth Date
o California Drivers License o Passport
o Birth Certificate o DMV ID
Renters Agreement (for Weatherization) authorizing weatherization work to be done. Homeowner Photo ID with the Property Tax Bill.
Social Security Card: or Legal Document with applicant’s name and SS#. Proof of All Income, Current from the Last 30 Days:
Applies to All Household Members with Any Income from the Age of 18 years and Older.
o Temporary Assistance for Needy Families (TANF): Notice of Action, computer printout, benefit letter, copy of welfare check. Date if Document must be within 30 Days.
o 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. Award Letter
indicating income for current year.
o Social Security: copy of current check(s), SSA Form 4926, or 2458, computer printout from Social Security Administration Office, Bank Statement showing direct deposit,.
o Pension and Annuities: copy of a current check, verification on letterhead or annual statement from pension plan.
o Wages: Copy of current paycheck stub(s) covering a one-month period and showing gross income.
o Interest Income: monthly or quarterly bank statement, statement of interest income from bank or agency. o Disability Compensation: copy of a current check, printout or letter from agency or insurance company
verifying the compensation amount.
o Unemployment Benefits: copy of current checks(s), printout from Employment Development Department. o Child and/or Spousal support: copy of current check.
o Support from an Individual: copy of check and statement signed by person providing the support. o General Assistance: Notice of Action from County Social Services, copy of a current check.
o Veteran’s Benefits: letter indicating receipt of Veteran’s Pension, copy of Veteran’s Administration check. o Signed Federal Tax Form 1040 (valid through April 15, 2011): WILL ONLY BE ACCEPTED FOR SELF-EMPLOYED o Other: (describe) _______________________________________________________________
DESCRIPTION OF SERVICES
Utility Payment Assistance
Once-a-year assistance with paying a costly energy utility bill is available to income qualified California households
under the Low-Income Home Energy Assistance Program
Home Energy Assistance Program (HEAP) provides a direct payment to an eligible client’s utility
bill to help offset the cost of heating or cooling their home.
Fast Track provides a direct payment to an eligible client’s utility bill if there the client is in a
crisis situation; such as receiving a 24 or 48 hour disconnect notice, or service termination by a utility company, or an energy-related crisis or life-threatening emergency existing in the household.
Weatherization
Provides free energy efficiency upgrades to the dwellings of low-income families to lower their monthly utility bills. Homes may only be weatherized ONE time in the life of the home. You do not have to own your home to be eligible. Renters that qualify must have permission from their Landlord (see attached form CSD 515)
Weatherization for single family homes, apartments, condos and mobile homes. Improvements such as repair
to heating and cooling systems, duct work, insulation, refrigerator, shower heads , faucet aerators, CFL light bulbs and more may be available after the dwelling is assessed for qualifying
measures.
Energy Crisis Intervention Program (ECIP)/HCS (Heating and Cooling Services) provides assistance to low-income households that are in a crisis
