Fillable LIHEAP Eng App Color2021

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LIHEAP Eng App Color2021

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P.O. Box 4317, Hayward, CA 94540-4317 - 510-881-0300 - www.SpectrumCS.org
(LIHEAP)
Helping Alameda County residents
with paying their PG&E/Alameda Municipal Power Bill
Spectrum Community Services
LIHEAP Program
P.O. Box 4317
Hayward, CA 94540-4317
www.SpectrumCS.org
PLEASE DO NOT USE WHITE OUT.
www.SpectrumCS.org
LIHEAP APP
P.O. Box 4317, Hayward, CA 94540-4317 - 510-881-0300 - www.SpectrumCS.org
LIHEAP Eligibility Applicant Agreement
Because of significant funding cuts, the federal government enacted a law requiring that states target
households with low incomes and high energy costs, taking into consideration households with elderly and
disabled persons, and children under six. This means there could be households that received assistance in
the past and will no longer receive assistance because they fall into a low priority group and are not consid-
ered among the neediest on the needy.
Eligibility is based on the household’s total monthly income, which cannot exceed the 2021 LIHEAP Income
Guidelines listed below. The chart below shows the gross income guidelines for this program:
HOUSEHOLD SIZES MONTHLY GROSS INCOME
1
$2,431.09
2
$3,179.11
3
$3,927.14
4
$4,675.17
5
$5,423.19
6
$6,171.22
2021 Monthly Gross Income Guidelines
Please remember LIHEAP is not an entitlement program. Spectrum also offers weatherization services to
help households’ lower their utility bills. All applicants are encouraged to continue paying on their energy bill.
I understand and have read the above.
_______________________________________ ___________
Signature Date
Questions? Please call us at 510 881-0300
Page1of2
Firstname MiddleInitial LastName DateofBirth

MM/DD/YY
SERVICEADDRESS
–
Addresswhereyoulive(thiscannot beaP.O.Box)
ServiceAddress UnitNumber
ServiceCity ServiceCounty ServiceState ServiceZipCode
Haveyoulivedatthisresidenceduringeachofthepast12months?……………………………………………………………………..☐Yes☐No
Isyourserviceaddressthesameasmailingaddress?...................................................................................................☐Yes☐No
MailingAddress UnitNumber
MailingCity MailingCounty MailingState MailingZipCode
SocialSecurityNumber
(SSN):

 TelephoneNumber()
E‐mailAddress:
HOUSEHOLDMEMBERS
ENTERTHEINFORMATIONBELOWFORALLHOUSEHOLDMEMBERS.
Ifyouhavemorethan7peopleinyourhousehold,pleaselisttheinformationonaseparatepieceofpaper.
FirstName LastName
Relationto
Applicant
DateofBirth
MM/DD/YY
AmountofGross
MonthlyIncome
(Before
TaxesandDeductions)
SourceofIncome
 Self 






HouseholdTotalMonthlyGrossIncome $
AreyouorsomeoneinyourhouseholdCURRENTLYreceivingCalFresh(FoodStamps)?☐Yes☐No
DepartmentofCommunityServicesandDevelopment
OfficialUseOnly:
EnergyIntakeForm
PriorityPoints
CSD43(10/2017)
A.C.C.
Agency:IntakeInitials:IntakeDate:
EligibilityCertDate
PEOPLELIVINGINHOUSEHOLD
Enterthetotalnumberofpeople
livinginthehousehold,
includingyourself
INCOME
Enterthetotalnumberofpeople
whoreceiveincome

Demographics:Enterthenumberofpeopleinthe
householdwhoare
:
Enterthetotalgrossmonthlyincomeforallpeoplelivingin
thehousehold:
Ages0–2Years
TANF/CalWorks $
Ages3‐5years
SSI/SSP $
Ages6‐18years
SSA/SSDI $
Ages19‐59
Paycheck(s) $
Ages60andolder
Interest $
Disabled
Pension $
NativeAmerican
Other $
SeasonalorMigrantFarmworker
TotalMonthlyIncome $
WEB
Page2of2
PAYBILL
Towhichenergybill(CHOOSEONLYONE)doyouwanttheLIHEAPbenefittobeapplied?(Attachcompletecopyofmostrecentbillorreceipt)
☐NaturalGas☐Electricity☐Wood☐Propane☐FuelOil☐Kerosene☐OtherFuel
Entertheenergycompanyandaccountnumber:
CompanyName:___________________________________________Account#:_______________________________________
Isyourutilityserviceshut‐off?☐Yes☐No
Doyouhaveapastduenotice?☐Yes☐No
Areyourutilitiesincludedinrentorsubmetered?☐Yes☐No
Areyourutilitiesallelectric?☐Yes☐No
IsyourNaturalGasCompanythesameasyourElectricCompany?☐Yes☐No
WOOD,PROPANEorFUELOILSERVICE(WPO)
Areyoucurrentlyoutoffuel?(Wood,Propane,Oil,Kerosene,OtherFuels)☐Yes☐No☐N/A
Listtheapproximatenumberofdaysuntilyourunoutoffuel(Wood,Propane,Oil,Kerosene,OtherFuels).
NumberofDays:___________
☐N/A
ENERGYINFORMATION
ThequestionsbelowareMANDATORY.Pleasecheckallenergysourcesusedtoheatyourhome.
Acopyofallrecentenergybillsand/orreceiptsforanyhomeenergycostmustbeprovided.
NOTE:Acopyofanelectricbillmustbeincludedevenifyoudonotuseelectricitytoheat
yourhome.
WhatisthemainfuelusedtoHEATyourhome?OnemainheatingsourceMUSTbechecked.
☐NaturalGas☐Electricity☐Wood☐Propane☐FuelOil☐Kerosene☐OtherFuel
Inadditiontoyourmainheatingsource,doyoueveruseanyofthefollowingtoheatyourhome(youcanselectmorethanone):
☐NaturalGas☐Electricity☐Wood☐Propane☐FuelOil☐Kerosene☐OtherFuel☐N/A
Areyoutheaccountholder:ElectricBill☐Yes☐NoNaturalGasBill☐Yes☐No
Theinformationonthisapplicationwillbeusedtodetermineandverifymyeligibilityforassistance.Bysigningbelow,Igivemyconsent(permission)
toCSD,itscontractors,consultants,otherfederalorstateagencies(CSDPartners)andtomyutilitycompanyanditscontractors,toshareinformation
aboutmyhousehold’sutility
account,energyusageand/orotherinformationneededtoprovideservicesandbenefitstomeasdescribedattheend
oftheform.Myconsentshallbeeffectivefortheperiodbeginning24monthspriorto,andcontinuingfor36monthsafter,thedatesignedbelow.I
understandthatifmyapplicationforLIHEAP/DOEbenefitsorservicesisdenied,orifIreceiveuntimelyresponseorunsatisfactoryperformance,I
mayinitiateawrittenappealwiththelocalserviceproviderandmyappealshallbereviewednolaterthan15daysaftertheappealisreceived.IfIam
notsatisfiedwiththelocalserviceprovider'sdecisionImaythenappealtotheDepartmentofCommunityServicesandDevelopmentpursuantto
Title22,CaliforniaCodeofRegulationssection100805.Ifapplicable,Iherebyauthorizeinstallationofweatherizationmeasurestomyresidenceatno
costtome.Ideclare,underpenaltyofperjury,thattheinformationonthisapplicationistrue,correct,andthatthefundsreceivedwillbeusedsolely
forthepurposeofpayingmyenergycosts.
X
***APPLICANT’SSIGNATURE***
Date
AGENCYNAME:CommunityServicesandDevelopment(CSD).UNITRESPONSIBLEFORMAINTENANCE:HomeEnergyAssistanceProgram(HEAP).
AUTHORITY:GovernmentCodeSection16367.6(a)NamesCSDastheagencyresponsibleformanagingHEAP.PURPOSE:Theinformationyou
providewillbeusedtodecideifyouareeligibleforaLIHEAPpaymentand/orweatherization
services.GIVINGINFORMATION:Thisprogramis
voluntary.Ifyouchoosetoapplyforassistance,youmustgiveallrequiredinformation.OTHERINFORMATION:CSDusesstatisticaldefinitionsfrom
theannualupdateoftheDepartmentofHealthandHumanServices'StateMedianIncome,FederalIncomePovertyGuidelines,todetermine
programeligibility.Duringapplicationprocessing,CSD'sdesignatedsubcontractormayneedtoaskyouformoreinformationtodecideyour
eligibilityforeitherorbothprograms.ACCESS:CSD'sdesignatedsubcontractorwillkeepyourcompletedapplicationandotherinformation,ifused,
todetermineyoureligibility.Youhavetherighttoaccessallrecordsholdinginformationabout
you.CSDdoesnotdiscriminateintheprovisionof
servicesonthebasisofrace,religiouscreed,color,nationalorigin,ancestry,physicaldisability,mentaldisability,medicalcondition,maritalstatus,
sex,age,orsexualorientation.
APPLICANT:DONOTFILLOUTTHEINFORMATIONBELOW.THISSECTIONISFOROFFICIALUSEONLY.
UtilityAssistancebeingprovidedunderwhichprogram☐HEAP☐FastTrack☐HEAPWPO☐ECIPWPO
BaseBenefit$_______________Supplement$_______________TotalBenefit$_______________


TotalEnergyCost$________________________EnergyBurden_________________________
Energy Services Restored after disconnection: ☐ Yes ☐ No Disconnection of Energy Services prevented: ☐ Yes ☐ No
Home Referred for WX: ☐ Home Already Weatherized: ☐
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)
(City)
State
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)
(City)
State
CA
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
Spectrum Community Services
P.O. Box 4317, Hayward, CA 94540-4317 - 510-881-0300 - www.SpectrumCS.org
Low Income Home Energy Assistance Program
Please remember to submit:
1. YOUR APPLICATION
2. COMPLETE PG&E or ALAMEDA MUNICIPAL BILL must be within 30 days, please include your 15-day, 48-hour,
or Shut-off notice if you have one.
a) PROOF OF INCOME —within the last 30 days, payroll checks (if weekly=4; biweekly=2)
b) SSI/SSA—2021 Award Letters, bank statements, Treasury deposit, or copy of SSI/SSA
c) EDD—Last 4 weeks of pay stubs or payment history
d) GA (General Assistance)—Cal-Learn, CalWORKS, Food Stamp notice of action letter or printout within
the last 30 days
e) Loans—If you are receiving help from friends and relatives, (if it is monthly, we will need a signed letter
with the specific amount, dates, and telephone number).
f) Self-employed—We will need signed taxes (all pages on the bottom signed) with the Schedule C, or
Ledger, or Receipt book with the last 30 days.
g) Pensions, Annuities and IRA’s—We will need the Award Letter for the last 30 days or Lifetime Award
Letter. No bank statement
h) Child support
PROOF OF DISABILITY (at least one of following):
a) SSI/SSA—Award letter 2021
b) Physician’s statement letter
c) EDD letter indicating disability and payment history
d) DMV Placard with letter stating disability
HOUSEHOLD MEMBER OVER 60 (at least one of following for Weatherization):
a) ID card
b) Insurance card
c) Birth Certificate
CHILDREN 5 AND UNDER (at least one of following for Weatherization):
a) Birth Certificate
b) Immunization record
c) Insurance Card with birthdate
d) Medical Record with birth 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
P.O. Box 4317, Hayward, CA 94540-4317 - 510-881-0300 - www.SpectrumCS.org
Budget Counseling Form
Why a budget?
A budget is a spending plan that makes your aware of where your money is going and what is im-
portant to you. This is a one-month budget plan to give you an example of how to spend your money.
Please fill out the budget information below so you can see for yourself where your money goes.
Income
Expense
Remaining Funds
$
Monthly Gross In-
come (Before Taxes)
$
Monthly Net Income
(Minus taxes)
$
Total Income $
Rent / Mortgage
$
Food
$
Water
$
Telephone
$
Garbage
$
Gas
$
Electric
$
Total
$
Monthly Income Monthly Expense
=
_
Put Notary stamp below, if needed (DOE only) or have
Executive Director Sign here
Department of Community Services and Development
CSD 43B (rev.12/2013)
CERTIFICATION OF INCOME AND EXPENSES
Y
ou are being asked to complete this form because you requested assistance, and state that your entire household cannot provide proof
of income. The State of California requires the applicant to report all sources of income. This form will help us understand how you are
meeting expenses. Please complete the information below:
Name and Address
Name:
Address:
Section 3: Please tell us how you paid these monthly expenses during the previous months:
EXPENSE
MONTHLY
COST
HOW HAS THE EXPENSE BEEN PAID? IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:
Rent or
Mortgage
$
Name:
Phone:
Address:
Utility
Bills
$
Name:
Phone:
Address:
Food $
Name:
Phone:
Address:
Section 4: If none of the above applies to you, please explain how your monthly expenses were paid:
Signature:
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
Section 1: Do you have sources of income you forgot to report?
YES NO
During the previous month have you been employed part time?
YES NO
During the previous month have you been self-employed?
YES NO
During the previous month did you receive money for any work that you perform only once in a while, like yard work,
child care, donating blood, etc?
YES NO
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:
YES NO
During the previous month did you receive any of the following: (circle any that apply)
WORKER’S COMP
UNEMPLOYMENT
GOVERNMENT SPONSORED BENEFITS
CHILD SUPPORT
YES NO
Do you receive any of the following (circle any that apply)
ANNUITY PAYMENT
PENSION
TRIBAL CASINO PAYMENTS
RENTAL INCOME
INSURANCE BENEFITS
Section 2: Are you spending your savings or borrowing money to
cover monthly expenses?
YES NO
Are you using savings or a home equity loan?
How much? ____________________________
YES NO
Are you using some other asset?
How much?____________________________
YES NO
Are you borrowing from credit cards?
How much?____________________________
YES NO
Are you borrowing from some other source?
How much?____________________________
Put Notary stamp below, if needed (DOE only) or have
Executive Director Sign here
Department of Community Services and Development
CSD 43B (rev.12/2013)
CERTIFICATION OF INCOME AND EXPENSES
Y
ou are being asked to complete this form because you requested assistance, and state that your entire household cannot provide proof
of income. The State of California requires the applicant to report all sources of income. This form will help us understand how you are
meeting expenses. Please complete the information below:
Name and Address
Name:
Address:
Section 3: Please tell us how you paid these monthly expenses during the previous months:
EXPENSE
MONTHLY
COST
HOW HAS THE EXPENSE BEEN PAID? IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:
Rent or
Mortgage
$
Name:
Phone:
Address:
Utility
Bills
$
Name:
Phone:
Address:
Food $
Name:
Phone:
Address:
Section 4: If none of the above applies to you, please explain how your monthly expenses were paid:
Signature:
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
Section 1: Do you have sources of income you forgot to report?
YES NO
During the previous month have you been employed part time?
YES NO
During the previous month have you been self-employed?
YES NO
During the previous month did you receive money for any work that you perform only once in a while, like yard work,
child care, donating blood, etc?
YES NO
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:
YES NO
During the previous month did you receive any of the following: (circle any that apply)
WORKER’S COMP
UNEMPLOYMENT
GOVERNMENT SPONSORED BENEFITS
CHILD SUPPORT
YES NO
Do you receive any of the following (circle any that apply)
ANNUITY PAYMENT
PENSION
TRIBAL CASINO PAYMENTS
RENTAL INCOME
INSURANCE BENEFITS
Section 2: Are you spending your savings or borrowing money to
cover monthly expenses?
YES NO
Are you using savings or a home equity loan?
How much? ____________________________
YES NO
Are you using some other asset?
How much?____________________________
YES NO
Are you borrowing from credit cards?
How much?____________________________
YES NO
Are you borrowing from some other source?
How much?____________________________
P.O. Box 4317, Hayward, CA 94540-4317 - 510-881-0300 - www.SpectrumCS.org
Energy Tips
Energy Savings
Replace your old refrigerator, washer/dryer, and dishwasher with energy-efficient models. Energy
Star® appliances are recommended.
Turn off your lights when you leave the room.
See if your home can receive attic or floor insulation.
Caulk windows, doors and anywhere air leaks in or out. Do not caulk around water heater and fur-
nace exhaust pipes.
Weather-strip around windows and doors.
Wrap heating and cooling ducts with duct wrap.
Change to Light Emitting Diode (LED) light bulbs.
Turn off electronics and power strips when they are not in use.
Dry clothes outside in good weather.
HEATING
Set the furnace thermostat at 68 degrees or lower during the day.
Health permitting set thermostat at 55 ° at night or off.
Have a professional inspect and tune up your furnace.
Clean or replace furnace filters once a month.
Check air vents, radiators, and registers.
Wear a sweater or clothing in layers to trap body heat.
Open drapes to let sun heat your home during the day and close them at night to help insulate.
Close off unused rooms and vents that heat those rooms.
Close your fireplace damper tightly when not in use.
Close doors and windows.
Replace old windows with new dual pane windows.
Never use the kitchen stove, oven or BBQ to heat your home.
P.O. Box 4317, Hayward, CA 94540-4317 - 510-881-0300 - www.SpectrumCS.org
COOLING
Set the thermostat at 78 degrees in summer or off.
Use a fan and natural ventilation first.
Wear cooler clothing.
Window coverings should be closed during the day in summer to keep the heat out.
WATER
Buy a water heater that is sized for your household needs. Energy Star®
Turn down the water heater thermostat to 120° F.
Insulate old water heater tanks; new units are insulated internally.
Install low-flow showerheads.
Take shorter showers.
Fix leaky water faucets and install low-flow aerators on the faucets.
Wash full loads in your dishwasher and use air-dry option on your dishwasher.
Wash full loads and use cold water when washing clothes.
For more energy tips, please visit: https://www.energyupgradeca.org/
For information on our programs, or to download our HEAP application, please visit our web site: www.SpectrumCS.org
or please contact us at 510-881-0300.
Follow us on Facebook @SpectrumCommunityServicesinc or on Twitter @Spectrum_CS.
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Completed 29 January 2021

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