Csd 43 Energy Intake Form – Fill Out and Use This PDF

PAY BILL

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

☐ Natural Gas ☐ Electricity ☐ Wood ☐ Propane ☐ Fuel Oil ☐ Kerosene ☐ Other Fuel Enter the energy company and account number:

Company Name: ___________________________________________ Account #: _______________________________________

Is your utility service shut-off?	☐ Yes	☐ No
Do you have a past due notice?	☐ Yes	☐ No
Are your utilities included in rent or submetered? ☐ Yes			☐ No
Are your utilities all electric?	☐ Yes	☐ No
Is your Natural Gas Company the same as your Electric Company? ☐ 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

ENERGY INFORMATION

The questions below are MANDATORY. Please check all energy sources used to heat your home.

A copy of all recent energy bills and/or receipts for any home energy cost must be provided.

NOTE: A copy of an electric bill must be included even if you do not use electricity to heat your home.

What is the main fuel used to HEAT your home? One main heating source MUST be checked.

☐ 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):

☐ Natural Gas ☐ Electricity ☐ Wood	☐ Propane	☐ Fuel Oil ☐ Kerosene	☐ Other Fuel	☐ N/A
Are you the account holder: Electric Bill	☐ Yes	☐ No Natural Gas Bill	☐ Yes	☐ No

The information on this application will be used to determine and verify my eligibility for assistance. By signing below, I give my consent (permission)

to CSD, its contractors, consultants, other federal or state agencies (CSD Partners) and to my utility company and its contractors, to share information about my household’s utility account, energy usage and/or other information needed to provide services and benefits to me as described at the end

of the form. My consent shall be effective for the period beginning 24 months prior to, and continuing for 36 months after, the date signed below. I 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.

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
Base Benefit $_______________		Supplement $_______________			Total Benefit $_______________
Total Energy Cost $________________________			Energy Burden _________________________
Energy Services Restored after disconnection: ☐ Yes			☐ No	Disconnection of Energy Services prevented: ☐ Yes ☐ No
Home Referred for WX: ☐	Home Already Weatherized:			☐

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COMPLETE, SIGN, AND RETURN THIS FORM