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Page 1 of 2
First name
Middle Initial
Last Name
Date of Birth
MM/DD/YY
SERVICE ADDRESS – Address where you live (this cannot be a P.O. Box)
Service Address
Unit Number
Service City
Service County
LOS ANGELES
Service Zip Code
Have you lived at this residence during each of the past 12 months? ……………………………………………………………………..
☐
Yes
☐
No
Is your service address the same as mailing address?................................................................................................... ☐ Yes ☐ No
Mailing Address
Unit Number
Mailing City
Mailing County
LOS ANGELES
Mailing State
CA
Mailing Zip Code
Social Security Number
(SSN):
Telephone Number ( )
E-mail Address:
HOUSEHOLD MEMBERS
ENTER THE INFORMATION BELOW FOR ALL HOUSEHOLD MEMBERS.
If you have more than 7 people in your household, please list the information on a separate piece of paper.
First Name Last Name
Relation to
Applicant
Age
Date of
Birth
MM/DD/YY
Amount of Gross
Monthly Income
(Before Taxes and Deductions)
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 (10/2017)
A.C.C.
Agency: PACE Intake Initials: Intake Date:
Eligibility Cert Date
PEOPLE LIVING IN HOUSEHOLD
Enter the total number of people
living in the household,
including yourself
INCOME
Enter the total number of people
who receive income
Demographics: Enter the number of people in the
household who are:
Enter the 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 GR $
Seasonal or Migrant Farmworker
Total Monthly Income
$
Page 2 of 2
PAY BILL
To which energy bill (CHOOSE ONLY ONE) do you want the LIHEAP benefit to be applied?
☐ 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 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. CHOOSE ONE ONLY
☐
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.
X
* * * APPLICANT’S SIGNATURE * * *
Date
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:
☐
Home Energy Assistance Program Survey Form
In accordance with federally funded program requirements, please provide the following
demographic survey information. Please check all that apply.
Income and/or Other Support
1. ____ AFDC/TANF/CalWorks
2. ____ SSI/SSP
3. ____ SSA/Social Security
4. ____ Pension/Retirement/Annuity
5. ____ Employment, IHSS, Crystal Stairs
6. ____ Self-employment
7. ____ CAPI
8. ____ EDD/SDI (State Disability)
9. ____ Workers Compensation
10. ____ GR
11. ____ Adoption/Foster Care
12. ____ Investment/Interest
13. ____ VA Benefits
14. ____ Child/Spousal Support
15. ____ Family Support
16. ____ Rental Income
17. ____ Savings
18. ____ CalFresh (Food Stamps)
19. ____ Other: (list below)
___________________________________
___________________________________
I consider myself to be:
20. ____African American
21. ____Armenian
22. ____Caucasian
23. ____Chinese
24. ____Filipino
25. ____Korean
26. ____Latino
27. ____Native American Indian
28. ____Vietnamese
29. ____Other: (list here
) ___________________
Housing
30. _____ I have SECTION 8 or HUD
My monthly portion is $____________
31. _____ I RENT an apartment.
My monthly rent is $_____________
How many units are in your complex? ________
32. _____ I RENT a house.
My monthly rent is $____________
33. _____ I OWN my house.
My monthly mortgage payment is $
___________
FREE Weatherization Program - Energy Savings for Your Home
34. ____ Check to receive a free weatherization eligibility application.
You may be eligible to receive at no cost to up to $3055 worth of energy saving and
weatherization work done to your home (low income, other eligibility & assessment
requirements apply). This program is funded by Health & Human Services, administered by
the Department of Community Services & Development.
35.____ I RENT A HOUSE 37.____ I RENT AN APARTMENT
36.____ I OWN A HOUSE 38.____ I OWN AN APARTMENT
Home Energy Assistance Program (HEAP) Procedures
Please read and acknowledge by signing below:
1) The HEAP program is a once a year utility bill assistance program (only 1 bill per year, per household).
2) The HEAP program is not an entitlement program.
3) All can apply, but not all may qualify.
4) If your application qualifies, a credit will be posted to your utility account that you specified on this application.
5) If your application does not qualify, you will be notified by mail.
6) PACE does not call the utility company on your behalf for any reason.
7) PACE does not make any payments.
8) All payments/credits are made and/or applied to the utility company by the California State Department of
Community Services and Development.
9) No utility bill is paid immediately and it may take up to 5 months. You will need to make your own
arrangements directly with the utility companies to avoid service disconnection.
I, ___________________________________, have read and understand the HEAP Program Procedures.
(Print Name)
Signature: ___________________________________ Date: _____________________________________
Lead-Safe
Energy Mold/Moisture Budget Counseling Radon
Date Time Date Time Date Time
Lead-Safe
Energy Mold/Moisture Budget Counseling Radon
Date mailed
Self-Certification Option
If the information was delivered but a signature was not obtainable, you may check the appropriate box below.
I certify that I attempted to deliver the following educational information to the dwelling listed above:
Radon Education - A copy of the pamphlet,
A Citizen's Guide to Radon
, informing me of the potential
risk of radon and how to lower the radon level in my dwelling unit.
State of California
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 321 (Rev. 12/05/11)
CLIENT EDUCATION CONFIRMATION OF RECEIPT
Attempted delivery dates and times
Signature (Agency Representative)
Signature (Agency Representative)
Print name
Mailing Option:
Refusal to Sign — I certify that I have made a good faith effort to deliver the information to the dwelling
unit listed above at the date and time indicated and that the occupant refused to sign the confirmation of
receipt. I further certify that I have left a copy of the information at the unit with the occupant.
Unavailable for Signature — I certify that I have made a good faith effort to deliver the information to
the dwelling unit listed above and that the occupant was unavailable to sign the confirmation of receipt. I
further certify that I have left a copy of the information at the unit by sliding it under the door.
I certify that I have mailed the following educational information to the dwelling listed above (attach copy of
Certificate of Mailing for lead-safe education only):
Print name
Energy Education – Information regarding changes I can make in order to reduce the energy
consumption of my household.
Budget Counseling
- Information regarding personal financial management.
I have received the following information:
Date
Signature of Recipient
Mold and Moisture Education - A copy of the pamphlet, A Brief Guide to Mold and Moisture In Your
Home , informing me of how to clean up residential mold problems and how to prevent mold growth.
Confirmation of Receipt
Lead-Safe Education – A copy of the pamphlet, Renovate Right: Important Lead Hazard Information
for Families, Child Care Providers, and Schools
, informing me of the potential risk of the lead hazard
exposure from weatherization/renovation activity to be performed in my dwelling unit.
Name of Occupant
Age of Dwelling
Address of Dwelling
90001 90002 90003 90006 90007 90008 90009 90011 90012 90013 90014 90015 90017 90020 90021
90024 90025 90027 90028 90029 90030 90036 90037 90038 90039 90043 90044 90045 90046 90047
90048 90049 90050 90051 90052 90053 90054 90055 90057 90059 90060 90061 90062 90064 90066
90067 90068 90069 90071 90077 90079 90094 90210 90211 90212 90220 90221 90222 90223 90224
90231 90245 90247 90248 90249 90250 90251 90254 90260 90261 90266 90267 90272 90277 90278
90291 90292 90294 90295 90296 90301 90302 90303 90304 90305 90306 90307 90308 90309 90310
90311 90312 90401 90402 90403 90404 90405 90406 90407 90408 90409 90410 90411 90501 90502
90503 90504 90505 90506 90507 90508 90509 90510 90723 90745 90746 90747 90749 91201 91202
91203 91204 91205 91206 91207 91208 91209 91210 91502 91503 91505 91506 91521 91522 91523
91603 91608
The Pacific Asian Consortium in Employment (PACE) and the
Home Energy Assistance Program (HEAP) Help Pay Gas or Electric Bills
The PACE Home Energy Assistance Program (HEAP) is funded by the Federal Low Income Home Energy Assistance
Program through the State of California’s Department of Community Services & Development. Our mission is to help
low-income eligible and qualified households offset their heating and cooling costs by providing a once a year payment to
either their gas or electric bill.
The PACE HEAP program only serves the following Los Angeles County zip codes:
For more information and to check your application status:
213-989-3236 English/Spanish 213-989-3294 English/Spanish
213-989-3173 English/Spanish 213-989-3152 English/Spanish
213-989-3233 English/Armenian/Russian 213-989-3177 English/Spanish
213-353-1228 24 hour recorded message information line (do not leave a message)
Office Hours: Monday to Friday - 8:00 a.m. to 3:00 p.m.
Energy & Environmental Services
HEAP
1055 Wilshire Blvd.
Suite 900E
Los Angeles, CA 90017 web: www.pacela.org
Use it Wisely
Energy is Money
***HEAP DOES NOT PROVIDE PARKING OR VALIDATE***
To Determine Eligibility You Must Provide Copies of:
Your California Picture I.D.
Your Social Security Card
Your Current Electric Bill AND Current Gas Bill
Complete with all pages covering at least 22 service days with meter reading.
The recent Final Call or Shut-Off Notice from the electric or gas company.
Provide Proof of Current Monthly Incomes for all family members
This must show gross benefit amounts covering the past 30 days.
o TANF (AFDC), GR, Child Support, and others. Must be for current month.
o SSI, SSA, VA – Yearly award letter or printout dated within the last 30 days.
o Wages, EDD, SDI, Pension/Retirement, Workers Compensation.
All stubs must cover the past 30 days. Cash payment or contributions must
include date, name, and address of person providing cash.
Your Current Section 8/HUD contract showing your current monthly rent portion,
Rent Receipt and Lease Agreement, or Mortgage Statement.
NOTE: Additional documents may be required.
You Must Also Complete and Sign these Three Forms:
Energy Intake Form CSD 43
Home Energy Assistance Program Survey Form
Client Education Confirmation of Receipt Form CSD 321 (see back)
Applications cannot be processed if they are not completely filled out, missing a signature, or missing any documents.
IMPORTANT
1. Send copies only.
No documents will be returned.
2. Due to the popularity of this program,
applications may take up to 5 months to
process.
3. It is your responsibility to contact the
utility company for payment
arrangements to avoid disconnection.
4. There is no guarantee that you will
receive assistance until your application
is approved.
5. If your application qualifies, a payment
will be sent directly to the utility
company you selected and credited to
your utility account.
6.
If your application does not qualify, you
will be notified by mail.
7. Priority is given to the elderly, disabled,
families with young children, and
households with the lowest income and
highest energy costs.
Page 1 of 1
Department of Community Services and Development
Account Holder Authorization and Consent Form
CSD Form 081 (Rev. 12/17)
ACCOUNT HOLDER NAME(S) AND MAILING ADDRESS
Account Holder’s Full Name
Account Holder’s mailing address (Street)
Unit Number (if any)
(City)
State
Zip Code
Is the utility service address the same as the account holder’s mailing address? Yes No
Full Name of Applicant for Benefits (from Form 43)
Utility Service Address (Street)
Unit Number (if any)
(City)
State
CA
Zip Code
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 AND CONSENT
By signing this form, you (Account Holder) give your authorization and 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 property’s utility account, meter usage and energy consumption data, and other information as needed
for the period beginning 24 months prior to, and continuing for 36 months after, the date signed below. The information you
authorize us to obtain and share will be used for the purposes of evaluating home energy usage of program beneficiaries 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. CSD, its contractors, consultants, other federal or state
agencies and affiliated programs (CSD Partners), working cooperatively with your utility company and its contractors, use this
information to provide services that assist low-income families, such the applicant, to pay their home energy bills and mange
those energy needs for the purposes stated in this Authorization.
REVOCATION OF AUTHORIZATION AND 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.
APPLICABLE 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
Signature of Account Holder
Date
Name of CSD Contractor/Partner Organization
PACE - Pacific Asian Consortium in Employment
1
STATE OF CALIFORINA
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 515A (Rev. 2/12/16)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Owner-Occupant or Tenant Information
Owner-Occupant or Tenant (Print or type name)
Address
ENERGY SERVICE AGREEMENT FOR OCCUPANT
Dwelling Information
Select the Dwelling Type
I am the
Single-Family Mobile Home Multi-Unit Owner-Occupant Tenant
Apt./Unit No.
City
ZIP Code
Telephone Number
Owner-Occupant or Tenant Email Address
Owner-Occupant or Tenant FAX Number
Mobile home units only: I acknowledge that I may not receive services that require a permit if the registration on the mobile unit is not up-to-date.
Owner-Occupant or Tenant Acceptance of Terms for CSD Weatherization Services
(to be completed by the Owner-Occupant or Tenant)
I agree to accept the following TERMS required for my primary residence to receive services from the Department of Community Services and
Development (CSD) weatherization programs(s):
I acknowledge that the Rental Property Owner must grant the Contractor/Agency the same permissions by signing CSD 515B Energy Service
Agreement for Rental Property Owner before any services are rendered.
I certify that the above-listed property is my primary residence.
I (the Owner-Occupant or Tenant), grant the Contractor/Agency permission to enter my dwelling to perform assessments, conduct diagnostics, take
photos only of weatherization work to be performed or deferred (as it relates to individual or whole house services), install feasible weatherization
services and perform inspections in accordance with CSD weatherization program policies and standards to the above-listed dwelling.
I acknowledge that an assessment of my dwelling is necessary to determine the work that can be performed and that the work that is available may
be limited due to the needs and condition of my residence. Identified work may not be provided if it does not meet all program requirements and
specifications and may lead to full or partial deferral of work. My refusal of certain work may prevent the installation of other identified work in
accordance to program requirements.
I hereby release and pledge to hold harmless the Contractor/Agency listed below, and its staff, from any liability in connection with the work
identified on a summarized list, except as a consequence of gross negligence or willful and wanton misconduct.
I authorize the Contractor/Agency to access my utility company records to obtain only energy usage data for a period of one year before and two
years after weatherization measures are installed.
I grant the Contractor/Agency, local, State and/or Federal inspectors permission to enter the dwelling after reasonable notice to perform inspections
to verify the existence and quality of work performed by the Contractor/Agency and compliance with local, State, and/or Federal building codes and
programmatic guidelines and acknowledge that a permit may be required for specific weatherization work. I understand that I may be held
financially responsible for the weatherization work if I refuse to allow access for inspection and permitting purposes.
I shall not remove any permanently installed energy conservation measures unless they are damaged or no longer functional in the residence from
where they were installed.
I acknowledge and agree that this property is not for sale at the time of qualifying for the program and will not be offered for sale or otherwise
distributed for at least sixty days following the completion of weatherization services.
Additional Certifications For Owner-Occupants ONLY:
Additional Certifications For Tenants ONLY:
2
STATE OF CALIFORINA
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 515A (Rev. 2/12/16)
ENERGY SERVICE AGREEMENT FOR OCCUPANT
11.
12.
13.
1.
2.
3.
4.
5.
6.
Owner-Occupant or Tenant’s Signature
Date
I understand that the Property Owner cannot raise the rent of the unit for a period of two years from the date of weatherization because of the
increased value of the unit due solely to weatherization measures provided by the Contractor/Agency (allowable factors for rent increase 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/Agency, or actual increases in expenses of maintaining and operating this property).
I acknowledge that I have been provided a copy of this Agreement explaining its terms effective for a two year period after weatherization services
have been completed. Complaint Process: In the event the provisions of this Agreement related to increased rent or the landlord’s failure to
decrease utility costs for master metered units are not met, tenants may contact the Contractor/Agency to submit a verbal or written complaint,
which will be investigated by the Department of Community Services and Development. Contractor/Agency contact information is located on this
Agreement under the section entitled, “Contractor/Agency Assurance.”
Contractor/Agency Assurance
Contractor/Agency (Print name)
Address
I may retain the replacement energy conservation measure installed by the CSD weatherization program(s) if the replaced appliance was my
personal property .
I CERTIFY THAT I am the Owner-Occupant or Tenant residing in the dwelling listed above that serves as my primary residence and that all given
statements are true and correct to the best of my knowledge. I have read and understand these TERMS and RELEASE, and agree to be bound by all
of its terms and conditions in order to receive weatherization services under the CSD weatherization program(s).
CSLB Number (if applicable)
City
ZIP Code
Contractor/Agency Telephone Number
Contractor/Agency Email Address
Contractor/Agency FAX Number
The Contractor/Agency agrees to the following:
Shall be responsible for the feasible cost of weatherization measures performed other than cash contribution from the Owner or Owner Agent, if
applicable, and any subsequent non-compliance.
Shall ensure that the Contractor/Agency is properly insured.
Shall ensure that work is conducted in a professional manner and meets program and building code standards.
Shall not make any significant structural changes to the dwelling without requesting written permission specifically describing the change from the
dwelling owner.
Shall provide in writing a list of 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.
Agency Program Manager’s Signature
Agency Program Manager's Name (Print name)
Date
Rachelle Arizmendi
Pacific Asian Consortium in Employment (PACE)
1055 Wilshire Blvd.,Suite 900E
Los Angeles
90017
(213) 989-3255
(213) 989-3232
weatherization@pacela.org
Page 1 of 3
STATE OF CALIFORINA
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 515B (Rev. 2/12/16)
Single Mobile
City ZIP Code
City ZIP Code
City ZIP Code
Agent Email Address
Agent FAX Number
Apt./Unit No.
City
ZIP Code
Agent Telephone Number
Owner Email Address
Owner FAX Number
Apt./Unit No.
City
ZIP Code
Owner Telephone Number
If the Owner uses an agent for the above-referenced property, complete both Owner and Agent information.
Agent (Print or type name)
Address
List Qualified Units
List Vacant and Unqualified Units
Owner and Owner's Agent Information
Owner (Print or type name)
Address
# of Units in Building
# of Units to be Weatherized
# of Vacant & Unqualified Units
List Qualified Units
List Vacant and Unqualified Units
Building #3
Complex/Building Name (if applicable)
Building Address
# of Units in Building
# of Units to be Weatherized
# of Vacant & Unqualified Units
Building #2
Complex/Building Name (if applicable)
Building Address
# of Vacant & Unqualified Units
Number of Eligible Buildings in Complex: Use additional pages, if necessary.
Building #1
Building Address
Complex/Building Name (if applicable)
List Qualified Units
List Vacant and Unqualified Units
# of Units to be Weatherized
# of Units in Building
City
Zip Code
Type
Multi-Family Dwelling/Complex Information
ENERGY SERVICE AGREEMENT FOR RENTAL PROPERTY OWNER
Single-Family/Mobile Home Dwelling Information
Tenant Name
Dwelling Address
Page 2 of 3
STATE OF CALIFORINA
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 515B (Rev. 2/12/16)
ENERGY SERVICE AGREEMENT FOR RENTAL PROPERTY OWNER
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
I certify that I am the Owner (or Owner's Agent) of the above-listed rental property.
I grant the Contractor/Agency permission to enter my property to perform assessments, conduct diagnostics, take photos only of weatherization work
to be performed or deferred (as it relates to individual or whole house services), install feasible weatherization measures and perform inspections in
accordance with CSD weatherization program policies and standards to the above-listed rental property.
I acknowledge that an assessment of my property is necessary to determine the work that can be performed and that the work that is available may
be limited due to the needs and condition of my property. Identified work may not be provided if it does not meet all program requirements and
specifications and may lead to full or partial deferral of work. My refusal of certain work may prevent the installation of other identified work in
accordance to program requirements.
I shall not remove any energy conservation measures unless they are damaged or no longer functional in the rental property from where they were
installed. If the replaced item (i.e. refrigerator or other appliance) was the personal property of my tenant, the tenant shall retain the replacement
energy conservation measure installed by the CSD weatherization program(s).
Mobile home units only: I acknowledge that my property may not receive services that require a permit if the registration is not up-to-date.
I hereby release and pledge to hold harmless the Contractor/Agency listed below, and its staff, from any liability in connection with any work identified
on a summarized list except as a consequence of gross negligence or willful and wanton misconduct.
Additional Certification for Unoccupied Multi-Unit Dwellings ONLY:
I certify that I, as 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 be
charged at the utilities' costs in accordance with California Public Utilities Commission Code Section 739.5 or other applicable government
regulations.
I certify that I, as the Owner or Owner's Agent, shall not raise the rent of any weatherized unit for a period of two years from the date of weatherization
because of the increased value of the unit due solely to weatherization measures provided (allowable factors for rent increase 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/Agency, or actual increases in expenses of maintaining and operating this property).
I acknowledge and agree that this property is not for sale at the time of qualifying for the program and will not be offered for sale or otherwise
distributed for at least sixty days following the completion of weatherization services.
Owner or Owner's Agent Acceptance of Terms for CSD Weatherization Services
(to be completed by the Owner or Owner's Agent)
I agree that "rent" is defined as the tenant's monthly payment to the Owner (non-subsidized housing) or the contract rent (subsidized housing).
I shall submit to the Contractor/Agency a schedule of rents prior to commencement of work.
Federal, State or Local Government Rehabilitation Projects only: I certify that if a vacant unit is counted as being an eligible household for purposes
of meeting the minimum threshold for whole building weatherization (66% rule), then the unit will become occupied by an eligible family within 180
days after the completion of weatherization (CFR 440.22(b)(2)(ii)).
I agree to accept all of the following TERMS required for my rental property to receive services from the Department of Community Services and
Development (CSD) weatherization program(s):
I certify that I shall provide a copy of this Agreement explaining its terms to all tenants and subsequent tenants residing in the unit within the two year
period. Complaint Process: In the event the provisions of this Agreement related to increased rent or the landlord’s failure to decrease utility costs for
master metered units are not met, tenants may contact the Contractor/Agency to submit a verbal or written complaint, which will be investigated.
Contractor/Agency contact information is located on this Agreement under the section entitled, “Contractor/Agency Assurance.”
I authorize the Contractor/Agency to access my complex's utility company master-metered records to obtain only energy usage data for a period of
one year before and two years after weatherization measures are installed.
I grant the Contractor/Agency, local, State and/or Federal inspectors permission to enter the dwelling after reasonable notice to perform inspections to
verify the existence and quality of work performed by the Contractor/Agency and compliance with local, State, and/or Federal building codes and
programmatic guidelines and acknowledge that a permit may be required for specific weatherization work. I understand that I may be held financially
responsible for the weatherization work if I refuse to allow access for inspection and permitting purposes.
Page 3 of 3
STATE OF CALIFORINA
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 515B (Rev. 2/12/16)
ENERGY SERVICE AGREEMENT FOR RENTAL PROPERTY OWNER
1.
2.
3.
4.
5.
6.
Y N Y N
Required Documentation:
Rent schedule received from Property Owner, if applicable?
If applicable, CSD 75
completed?
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/Agency Program Manager’s Signature
Contractor/Agency Program Manager's Name (Print name)
Date
Shall ensure that the Contractor/Agency is properly insured.
Shall ensure that work is conducted in a professional manner and meets program and building code standards.
Shall not make any significant structural changes to the dwelling without requesting written permission specifically describing the change from the
dwelling owner.
Shall provide in writing a list of all weatherization measures installed in the rental unit.
Contractor/Agency Email Address
Contractor/Agency FAX Number
The Contractor/Agency agrees to the following:
Shall be responsible for the feasible cost of weatherization measures performed other than cash contribution from the Owner or Owner Agent, if
applicable, and any subsequent non-compliance.
CSLB Number (if applicable)
City
ZIP Code
Contractor/Agency Telephone Number
Contractor/Agency Assurance
Contractor/Agency (Print or type name)
Address
I CERTIFY THAT I am the Owner or Owner's Agent of the Dwelling or Complex listed above, and that all given statements are true and correct to the best
of my knowledge. I have read and understand these TERMS and RELEASE, and agree to be bound by all of its terms and conditions in order for my
property to receive weatherization services under the CSD weatherization program(s).
Owner’s (or Owner's Agent’s) Signature
Date
Rachelle Arizmendi
Pacific Asian Consortium in Employment (PACE)
1055 Wilshire Blvd., Suite 900E
Los Angeles
90017
(213) 989-3255
(213) 989-3232
weatherization@pacela.org
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Completed 8 March 2022

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