Fillable AACOG - Weatherization Assistance Program Application (City of Castroville)

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AACOG - Weatherization Assistance Program Application (City of Castroville)

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E
nclosed is your Weatherization Program application. The federal guidelines require
verification of
all income claimed for anyone living in the household whose age 18 and over.
The following checklist states everything needed for an application to be complete:
□ Proof of your household’s gross income for the past thirty days from the date you sign
the application, including all sources of income.
Pay stubs, social security and/or retirement/pension benefit verification letters, etc.
If proof of income cannot be provided fill the “Declaration of Income Stat ement
Form”.
Family Size
2017 LIHEAP
Annual Income
Monthly Income
1
$18,090
$1,507
2
$24,360
$2,030
3
$30,630
$2,552
4
$36,900
$3,075
5
$43,170
$3,597
□ Proof of U.S. Citizenship or Natural Residency
Birth Certificate and Photo ID or Passport
Qualified Alien Status documentation (Permanent Resident I -155 Card or other
immigration documentation proving legal status to receive federal benefits).
Please Note: This requirement is for the applicant only.
□ Copy of your electric and/or gas utility bills
Please make sure that your account number is visible.
We cannot accept disconnection notices
□ The consumption release section must be completed with the account holder’s name
and signature.
WEATHERIZATION ASSISTANCE PROGRAM APPLICATION
RETURN COMPLETED APPLICATIONS TO:
AACOG WEATHERIZATION DEPARTMENT
8700 TESORO, SUITE 160
SAN ANTONIO, TX 78217-6228
PHONE: (210) 362-5282 FAX: (210) 225-5937 EMAIL: WAP@AACOG.COM
A
djunto está su aplicación del Programa de Climatización. Las pautas federales requieren la
verificación de todos los ingresos reclamados por cualquier persona que viva en el hogar cuya
edad de 18 años y más. El seguimiento lista de comprobación indica todo lo necesario para que
una aplicación sea completa:
□ Prueba del ingreso bruto de su hogar durante los últimos treinta días a partir de la
fecha en que usted firma la solicitud, incluyendo todas las fuentes de ingreso.
Talones de pago, cartas de verificación de la seguridad social y / o de jubilación
/ pensión, etc.
Si no puede presentarse comprobante de ingresos, llene la "Declaración de
Declaración de Ingresos".
Tamaño de la familia
2017 LIHEAP
Ingresos Anuales
Ingreso mensual
1
$18,090
$1,507
2
$24,360
$2,030
3
$30,630
$2,552
4
$36,900
$3,075
5
$43,170
$3,597
□ Prueba de Ciudadanía de los Estados Unidos o Residencia Natural
Certificado de nacimiento e identificación con foto o pasaporte
Documentación sobre la condición de extranjero calificado (tarjeta de residente
permanente I-155 u otra documentación de inmigración que demuestre su
estatus legal para recibir beneficios federales).
Nota: Este requisito es solo para el solicitante.
□ Copia de sus facturas de electricidad y / o gasolina
Asegúrese de que su número de cuenta es visible.
No podemos aceptar avisos de desconexión
□ La sección de liberación de consumo debe completarse con el nombre y la firma del
titular de la cuenta.
APLICACIÓN DEL PROGRAMA DE ASISTENCIA A LA WEATHERIZATION
DEVUELVA LAS SOLICITUDES COMPLETADAS A:
AACOG WEATHERIZATION DEPARTMENT
8700 TESORO, SUITE 160
SAN ANTONIO, TX 78217-6228
PHONE: (210) 362-5282 FAX: (210) 225-5937 EMAIL: WAP@AACOG.COM
Weatherization Assistance Program Application
8700 Tesoro Drive, Suite 160
San Antonio, TX 78217
Phone: (210) 362-5282 Fax: (210) 225-5937 Email: wap@aacog.com
Applicant Information
Full Name:
Physical Address:
Mailing Address:
Zip Code:
County:
Mobile Phone:
Work Phone:
Email Address:
Secondary Contact (not living in the household)
Full Name:
Relationship:
Mobile Phone:
Work Phone:
Email Address:
Household Information
Is there a household member with military service or surviving spouse of a Veteran? □ Yes □ No
Has your home been assisted with weatherization measures? □ Yes □ No
If yes; date
Year Built: □ Site Built □ Apartment □ Condominium □ Duplex □ Mobile Home
Are you a: □ Homeowner □ Renter
If Renter; Landlord Name
Landlord Address
Mobile Phone:
Work Phone:
Email Address:
Building/Energy Information:
What type of energy is used to heat the home?
□
Natural Gas □ Electricity □ Bottled Gas □ Propane □ Other
What type of heating unit is used in the home?
□
Central
□ Unvented Space Heater □ Wall Furnace
□
Electric Heat Pump □ None
How many cooling units?
□
Window Units □ Evaporative Cooler_ □ Central
□None
Existing Water Heater? □ Yes □ No
□
Natural Gas □ Electricity □ Other □ Leaking
Stove Type? □ Natural Gas □ Electric
Does the home have insulation? □ Yes □ No □ Attic □ Wall
Does the home need repairs? □ Yes □ No
□
Roof Leaks □ Foundation Issues □ Water Stains □ Broken
Windows
Household Members and all Sources of Income
Full Name
Relationship
Monthly
Gross
Income
U.S.
Citizen
Birth
date
Gender
Ethnicity
Disabled
Social Security #
Applicant
□ Yes
□ No
□ Male
□ Female
□ Yes
□ No
□ Yes
□ No
□ Male
□ Female
□ Yes
□ No
□ Yes
□ No
□ Male
□ Female
□ Yes
□ No
□ Yes
□ No
□ Male
□ Female
□ Yes
□ No
□ Yes
□ No
□ Male
□ Female
□ Yes
□ No
PW PI Previous WAP __________
UB SAV
Referral: _______________________
I
ntake:_________________
C
ON ELI Date: __________________
Bexar
Stratbrush Realty Limited
P.O. Box 460362
Verification
APPLICANTS AUTHORIZATION, UNDERSTANDING AGREEMENT
My answers to all the previous questions, the statements I have made and the information I have provided are true and correct to the
best of my knowledge. I authorize the Texas Department of Housing and Community Affairs and its contracted agencies to contact
any source in order to solicit/verify information necessary for an eligibility determination. I will also provide with any information
necessary to verify my eligibility.
If I am eligible for weatherization services, I give permission to allow work on the residence listed on this form, I will cooperate fully
with AACOG, State and Federal personnel making myself available all phases of the Program (assessment, installation, City
inspection, final inspection and quality control review) Failure to do so could result in forfeiture of the (1) year warranty on the
measures installed.
I have been advised and understand that this application will be considered without regard to race, color, religion, creed, national
origin, sex, or political belief.
PENALTIES FOR FRAUD!
I am aware that I am subject to prosecution for providing false or fraudulent information or for omitting information that may affect my
eligibility for benefits. Whoever obtains or attempts to obtain services for which he/she is not entitled, by means of willful false
statements or other fraudulent means, may be considered guilty of a criminal offense and upon conviction may be fined and/or
imprisoned.
AUTORIZACIÓN, ACUERDO, Y ENTENDIMIENTO DEL SOLICITANTE
Mis respuestas a todas las preguntas anteriores y las declaraciones que he hecho son verdaderas y correctas según mi leal saber,
entender y creencia. Autorizo al "Texas Department of Housing and Community Affairs" y a sus agencias contratadas a
comunicarse con cualquier persona o agencia para verificar o solicitar información necesaria para la determinación de elegibilidad.
Acepto responsabilidad de dar al Departamento cualquier información que se necesite para verificar mi elegibilidad. De ser elegible
para recibir los servicios de Climatización del Hogar, doy permiso para que se hagan reparaciones a la residencia identificada en
esta solicitud. Cooperare plenamente con personas de AACOG, el Gobierno Estatal y Federal estando disponible durante todas
las fases del servicio (evaluación inicial, instalación, Inspección de la Ciudad e Inspección final), cual en lo mismo se incluyen
estudios tocantes la calidad del trabajo. De no cumplir con esta condición invalidará la garantía de un (1) año por los servicios
recibidos.
Me han avisado y entiendo que esta solicitud será considerada sin distinción de raza, color, religión, credo, origen nacional, sexo o
creencia política.
Applicant Signature:
Firma del Solicitante:
Date:
Fecha:
Signature of Individual completing application on applicants behalf:
Firma del Individuo completando la solicitud en nombre del solicitante:
Date:
Fecha:
12 Month Customer Billing Consumption Release Form
Agency: Alamo Area Council of Governments
Account Holder:
Address:
City:
Zip Code:
Phone:
Electric Company:
Account #:
Gas Company:
Account #:
I authorize the Texas Department of Housing and Community Affairs and its contracted agency to solicit/verify
information on my energy billing and consumption histories, both past and future, to extend the information is used only
to determine program eligibility and to provide data.
Signature (name as it appears on utility bill)
Date:
Print Name (name as it appears on utility bill)
San Antonio
Revised December 2016
DECLARATION OF INCOME STATEMENT
(DECLARACION DE INGRESOS)
Applicant Name (Nombre del Solicitante)
Applicant Last Name (Apellido)
Suffix (Sufijo)
Address (Dirección)
City (Ciudad)
Zip Code (Código Postal)
State the gross income for household members, 18 years and older, who have no documentation of the
income received in the 30 day period prior to the date of application for assistance: (Declarar el ingreso
recibido por los miembros de su hogar, que tienen 18 años de edad ó mas, y que no tienen documentación
de ingresos por los 30 dias antes del aplicar para asistencia)
Name (Nombre)
Gross Income Received (Ingreso Bruto Recibido)
Name (Nombre)
Gross Income Received (Ingreso Bruto Recibido)
Name (Nombre)
Gross Income Received (Ingreso Bruto Recibido)
Name (Nombre)
Gross Income Received (Ingreso Bruto Recibido)
My household has no documented proof of income due to the following situation (Mi hogar no tiene
prueba para documentar los ingresos por medio de tal razones):
I certify that the above information is true and correct to the best of my knowledge and belief. (Yo certifico
que la información proveida de los ingresos es verdadera y correcta según mi saber y creencia.)
I understand that the information will be verified to the extent possible; and that I may be subject to
prosecution for providing false or fraudulent information. (Comprendo que la información será verificada
hasta donde sea posible y que puedo ser enjuiciado por haber proveido información falsa ó fraudulenta.)
(Applicant Signature/Firma del Solicitante) (Date/Fecha)
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AACOG - Weatherization Assistance Program Application (City of Castroville)

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Completed 14 July 2020

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