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Home Energy Assistance Program
Please complete and mail in the following documents to submit your application
Programa de Asistencia de Energía
Por favor complete y envíe los siguientes documentos para entregar su solicitud
2016
Home Energy Assistance Application
All pages of your Current Energy Bill
Solicitud para el Programa de
Asistencia de Energía
Adjunte todas las Páginas de
Su Factura de Energía
Proof of Income for Past 30 Days for every adult 19 and
older, Children receiving SSI/SSA, TANF (Adults with no
income need to fill out Certification of Income and Expenses)
We do not return any documents
Comprobantantes de Ingreso de los últimos
30 Días para cada adulto mayor de 19 años años
(Adultos sin ingresos necesitan llenar Certificación de
Ingresos y Gastos )
Weatherization Service Agreement
Contrato de Servicio para Climatización
No Envíe Documentos Originales
See Energy Tips on reverse side
Ver Consejos de Energía en el reverso
Home Energy Assistance Program
1-877-278-6455
Energy Saving Tips
Consejos Para Ahorrar Energía
Many of these energy saving tips can be obtained by applying
to the Weatherization Program.
Varios de los siguientes consejos de energía pueden ser adquiridos a
través del programa de Climatización (Weatherization Program).
Replace your old light bulbs with ENERGY STAR ®
Compact Fluorescent Lamp (CFL) and save up to
$210 per year!
Reemplace sus bombillas actuales por unas de
ENERGY STAR ® Lámpara Fluorescente Compact
(CFL) y ahorre hasta $210 al año!
Turn off faucet while brushing your teeth and save
up to $161 per year!
Cierre la llave de agua mientras se lava los dientes y
ahorre hasta $161 al año!
Turn off/unplug appliances not in use and save up to
$131 per year!
Apague/desconecte electrodomésticos que no esté
usando en el momento y ahorre hasta $131 al año!
Remove and recycle second refrigerator/freezer and
save up to $409 per year!
Elimine o recicle su segundo refrigerador/congelador
y ahorre hasta $409 al año!
Plug air leaks and weather-strip your doors and
windows to save up to $464 per year!
Turn off unnecessary lights and save up to $161!
Turn Thermostat Down 1-2 degrees (68F) and save
up to $210 per year!
Tape fugas de aire y coloque tiras protectoras
(burletes) en ventanas y puertas y ahorre hasta $409
al año!
Apague las luces que no esté usando y ahorre hasta
$161 al año!
Take Shorter showers and save up to $161 per year!
Baje 1-2 grados su termostato (68F) y ahorre hasta
$210 al año!
Cook double the recipe and freeze half for later and
save up to $62 per year!
Tome duchas más cortas y ahorre hasta $161 al
año!
Cut water use by 10%-20% and save up to $107 per
year!
Cocine doble la receta y congele la mitad para otro
dia y ahorre hasta $62 al año!
Wash clothes in cold water and save up to $7 per
year!
Wash full loads of clothes and save up to $5 per
year!
Replace and recycle your old refrigerator and
purchase energy-efficient models. Units only 10
years old can use twice as much electricity as a new
ENERGY STAR ® labeled.
If you are interested in Budget Counseling, please
call 1-877-278-6455
Reduzca el uso de agua de 10%-20% y ahorre hasta
$107 al año!
Lave su ropa en agua fría y ahorre hasta $7 al año!
Lave cargas completas de ropa y ahorre hasta $5 al
año!
Reemplace y recicle su refrigerador y compre
electrodomésticos de bajo consumo de energía. Los
que tienen solo 10 años pueden usar el doble de
electricidad a diferencia de uno nuevo etiquetado
ENERGY STAR ®.
Si usted esta interesado en consejeria, porfavor
llame al 1-877-278-6455
Estimated annual saving of up to $2,088
Estimación de ahorros anuales hasta $2,088
KEEP THIS FOR YOUR INFORMATION
MANTEGNA ESTA INFORMACIóN PARA USTED
Agency:
Sacred Heart Community Service Serving Santa Clara County - 1 (877) 278-­‐6455
www.sacredheartenergy.org - (Please use blue or black ink.)
Intake Initials:
Intake Date:
First name
Middle Initial
2016
Official Use Only:
Priority Points
A.C.C.
Eligibility Cert Date
Job Control Code
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)
☐ Yes
Have you lived at this residence during each of the past 12 months…………………………………………………………………………………. ☐ Yes
☐ No
☐ No
Is your service address the same as mailing address?............................................................................................................
Service Address
Unit Number
Service City
Service County
Service State
Social Security Number (SSN):
Telephone Number (
Service Zip Code
☐Message Only?
)
E-mail Address (Optional):
PEOPLE LIVING IN HOUSEHOLD
INCOME
Enter the total number
of people living in the
household, including the applicant
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
$
HOUSEHOLD MEMBERS (Optional)
FULL NAME:
Full name is First Name, Last Name.
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.
RELATIONSHIP TO THE APPLICANT:
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
Mail/Drop-off application at: Sacred Heart Community Service, 1381 S. First Street, San Jose, CA 95110
2016
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: _____________
☐ Yes
Are your utilities included in rent or submetered?
☐ N/A
☐ 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
Mail/Drop-off application at: Sacred Heart Community Service, 1381 S. First Street, San Jose, CA 95110
CERTIFICATION OF INCOME AND EXPENSES FORM
The State of California requires the applicant to report all sources of income. If you are the applicant for HEAP and you DO NOT have income or
OR received cash income, please complete this form. All adults (19 or older) in your household that earn cash income and cannot provide proof,
must fill out this form.
Name of Adult: __________________________________________
Address: ________________________________________________________
Please check any that apply:
____I receive cash income from other sources (for example, house cleaning, yard work, babysitting, redeeming cans, bottles, selling personal items).
___ I have NO income (Go to Section 2)
____I am a full-time student with no income (Go to Section 2)
____ I work full time
Section 1:
Tell us about your income sources
1 During the previous month have you been employed part time?
YES
NO
2 During the previous month have you owned your own business?
YES
NO
3 During the previous month did you receive money for any work that you perform only once in a while, like yard work,
YES
NO
YES
NO
YES
NO
YES
NO
babysitting, donating blood, etc.?
4 During the previous month have you received any gifts of money from anyone? If yes, please list the name and phone
number of the person who gave you the gift:
5 During the previous month did you receive any of the following: (circle any that apply)
Worker's Comp
Unemployment
Government Sponsored Benefits
6 Do you receive any of the following (circle any that apply)
Annuity Payment
Section 2:
Pension
Tribal Casino Payments
Rental Income
Child Support
Insurance Benefits
How did you pay these monthly expenses during the previous months?
Expense
Monthly Cost
Rent or Mortgage
SSI/SSA or
Program
Using other Using credit Borrowing or other If someone elses pays your
expenses, please complete:
asset
cards
source?
$
Name:
Address:
Phone
Utility Bills
$
Name:
Address:
Phone
Food
$
Name:
Address:
Phone
Section 3:
If none of the above applies to you, please explain how your monthly expenses were paid
By signing this form, I affirm that I believe these facts are accurate and true. I give the Service Provider my permission to verify this information.
I may be held liable under federal or state law for knowingly making false or fraudulent statements.
_______________________________________________________
Signature
______________________________________________________
Date
CSD 43B (rv 2.2015)
Official Use: Put Notary stamp below, if needed
(DOE only) or have Executive Director sign here.
F
WEATHERIZATION SERVICE AGREEMENT
ACUERDO DE CLIMATIZACIÓN
Sacred Heart Community Service (Contractor) agrees to install certain weatherization and energy conservation measures at
NO COST TO THE OWNER for the following dwelling unit(s).
El Servicio Comunitario del Sagrado Corazón se compromete a instalar servicios gratuitos de climatización/insolación
para la unidad/es en este acuerdo.
SECTION/SECCIÓN 1: Must be completed by the applicant. If you are also the owner, please complete and sign SECTION 2.
Complete y firme la Sección 1. Si usted es el dueño, por favor complete la SECCIÓN 2.
Applicant Name/Nombre
Street Address/Domicilio
Apt#_______
Daytime phone number/# de teléfono durante el día:
(______)_________________________________________________
Please Check ONE ONLY/Marque UNO:
Owner/Dueño
OR/O
City/Ciudad
State
CA
Afternoon/evening phone #/ número de teléfono durante la tarde/noche:
(_______) __________________________________________________________
Please Check ONE ONLY/Marque UNO:
Renter/Inquilino
Single Home/Casa
Signature/Firma_______________________________________
SECTION/SECCIÓN 2:
Zip Code/Código
Apartment/Apartamento
Mobile Home/Casa Móvil
Date/Fecha:_____________________________
Must be completed and signed by owner/owner’s authorized agent./Esta sección require la firma del dueño de casa.
Name of Owner or Property Management Company
Nombre del dueño o agente autorizado:
Name of Property Management Company
Compañia que maneja la propiedad:
Mailing Address/Domicilio donde recibe correo:
Daytime Phone/Número de teléfono durante el día:
What year was this unit built? /¿En qué año fue construida esta casa?
Is this a HUD assited unit?/ ¿Está unidad es subsencionada por HUD?
____________________
Do not know/No lo sé
Yes/Si
No
Do not kno/No lo sé
Date/Fecha:____________________________
Owner’s Signature/Firma del Dueño:______________________
Owner/Dueño: By signing this form, the owner/owner’s agent, and the tenant grant the contractor permission to enter the dwelling unit and to
perform or install weatherization measures, minor home repair, and/or rehabilitation including, but not limited to, repair or replacement of doors and
windows, caulking, door thresholds, water heater blankets and pipe wrap, insulation, setback thermostat, carbon monoxide detectors, repair or
replacement of inefficient or unsafe gas appliances (furnaces/stoves/water heaters), and additional measures to prevent loss of heat and reduce the
amount of energy consumption to the above-described unit, and agree to the following:
1.
2.
3.
The owner/owner’s agent shall not raise the rent of the unit for a period of 2 years or evict the unit’s resident because of the increased value of the
unit due solely to weatherization measures, minor home repair, and/or rehabilitation provided by the contractor.
The owner/owner’s agent, and the tenant shall retain all applied measures in the residence that where installed.
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 weatherization measures, minor home repair, and/or rehabilitation are completed.
Sacred Heart Community Service agrees to the following:
1. Shall be responsible for the cost of weatherization measures, minor home repair, and/or rehabilitation performed.
2. Shall ensure that the agency is insured and shall be responsible for damage to unit premises, furnishing, and/or resident(s) that is caused by
weatherization activities, minor home repair, and/or rehabilitation.
3. Shall schedule weatherization services, minor home repair, and/or rehabilitation at the convenience of all parties.
4. Shall provide weatherization services, minor home repair, and/or rehabilitation only to tenants eligible under program requirements.
5.
Shall assure that the owner/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.
OFFICIAL USE ONLY. DO NOT FILL OUT INFORMATION BELOW.
Eligibility Intake Date:
DJSN:
JobSN:
AppSN:
Sacred Heart Community Energy Service--1381 South First Street--San José-CA 95110 - (1-877) 278-6455
www.sacredheartenergy.org
rv 2/15
F
FREE Home Weatherization Services for Renters & Homeowners!
Receive energy efficient upgrades to your home:
Windows
Furnaces
Refrigerators
Insulation
Porch Lamps
Doors
Water Heaters
Smoke Alarms
Weather Stripping
And much more
This Program is 100% FREE of cost to homeowners and renters, including residents of mobile homes.
Home Energy Assistance Program (HEAP) helps income-eligible families with a credit of $173-$289 on their energy bill.
Weatherizing your home could help lower your energy usage and utility costs.
You may qualify for HEAP & FREE Weatherization services if your monthly household gross income is less than the
income guidelines listed at the bottom of this page.
GRATIS
Programa de Climatización para el Hogar
Reciba reparos de eficiencia energética para su hogar:
Ventanas
Hornos
Refrigeradores
Insolación
Puertas
Calentadores de Agua
Detectores de humo
y mucho más
Este programa es 100% gratuito para propietarios de viviendas, inquilinos, y residentes de
casas móviles.
Programa de Asistencia de Energía para Hogar (HEAP) ayuda a familias con un crédito de
$173-$289 en su factura de energía. La climatización de su hogar podría ayudar a reducir su
consumo de energía y costos de servicios públicos.
Usted puede calificar para HEAP y servicios gratuitos de climatización si su ingreso familiar bruto
mensual es menos que la cantidad que figura en la Guía de Ingresos en la parte inferior de esta
página.
INCOME GUIDELINES / GUÍA DE INGRESOS
Size of Household/
Monthly Income/
Annual Income/
# de Personas en el Hogar
Ingreso Mensual
Ingreso Annual
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
$24,057.24
$31,459.56
$38,861.76
$46,263.96
$53,666.28
$61,068.48
$62,456.40
$63,844.32
$65,232.24
$66,620.16
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