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UTILITY ASSISTANCE & WEATHERIZATION APPLICATIONS INSTRUCTIONS SHEET
Please provide copies of the following (NO ORIGINALS)
(Please complete all applicable forms; lack of supporting documentation required may cause a delay in processing or a denial)
Proof of any income earned/received in the last thirty (30) days for all household members 18
years and older, such as:
CHECK STUBS
Short/Long Term Disability Benefits
AWARD LETTERS (SS, SSI, SSDI
ALIMONY
PENSIONS
UTILITY REIMBURSEMENT CHECK
TANF
HUD Verification Letter
SELF EMPLOYMENT
Food Stamps
WORKERS’ COMPENSATION
UNEMPLOYMENT BENEFITS
VA BENEFITS (Record of Military Services or
Benefits for Surviving Spouses or Dependents
DIRECT INCOME received from family/friend to
assist with expenses (We will need a letter from
the payee.)
Child Support (If not received through the Attorney
General, we will need a letter from the payee; we
may request CIN#, please have available)
HUD Verification Letter (Utility Allowance
Reimbursement documentation is require if
applicable)
● We cannot accept the following: Bank statements, W2 tax forms.
● We must receive a COPY of the original award letter from all government issued sources NO
EXCEPTION!!!!
• Copy of Photo ID(Required)
• If NO income has been earned/received, household members 18 years and older must complete a
Declaration of Income/No Income Statement (see our website or request a copy)
• Current copy of ELECTRIC, GAS, or PROPANE bill (front & backside)
• Social Security numbers & Dates of Birth for all household members
• A Case Manager/Eligibility Specialist will call you once application is complete, please provide a
daytime phone number.
•
The
General Authorization for Release of Information
must be completed by the
ACCOUNT
HOLDER
or
AUTHORIZE USER
on the account.
• You must complete all forms attached to this instruction form that are applicable to your
household or your request will be delayed or denied.
•
Complete Systematic Alien Verification Form (SAVE).
UTILITY ASSISTANCE ONLY - ALL FEES MUST BE PAID BEFORE WE CAN ASSIST WITH BILL
Continue to pay any outstanding bills until you receive a confirmation letter from us stating
that you are on the program. Once application is received, allow up to 60 days for processing.
Applications are processed in order it is received and by priority rating scale.
**Application is not a guarantee of services, you
must qualify for programs**
Do not submit application until you have all the
information required and application is filled out and
signed completely.
If you are missing required documents; we will contact you and make you aware of the missing
documents. Then you will have 7 business days to provide information, or your application will be
shredded unless other arrangements are made in advance.
Documentation for establishing United States Citizenship and Identity for the (CEAP)
Comprehensive Energy Assistance Program, (LIHEAP) Low Income Home Energy Assistance
Program, (WAP) Weatherization Assistance Program is required.
Failure to provide required documentation may result in your application being denied or
delayed.
WEATHERIZATION APPLICATIONS
Landlord Permission Form – RENTERS ONLY (see our website or request a copy)
You must include a map or brief description of your home on page 3 of your application
Weatherization DOES NOT include windows, doors, flooring, roofing, wiring, or
plumbing.
Weatherization:
Assessments are scheduled by our staff by phone call or home visit. After two (2)
attempts to reach you with no response, your application will be denied.
You are allowed to reschedule an assessment one (1) time. Any subsequent attempts
to reschedule an assessment will cause your application to be denied.
Any missed appointment for an assessment with no prior notice will cause your
application to be denied.
Any home that is considered a health and safety risk to our staff or contractors will be
subject to further review at GETCAP’s discretion.
Applications and all supporting documents may be returned in person, by mail or email, or by
fax.
Physical address: 1716 South Street, Nacogdoches, Texas 75964
Mailing address: P.O. Box 631938, Nacogdoches, TX 75963
(Please include proper postage – mail with insufficient funds will be returned)
Email address: programinfo@get-cap.org
Fax number: Energy Assistance: 936.564.0302 or Weatherization: 936.462.9157
PROOF OF CITIZENSHIP AND PROOF OF IDENTITY IS REQUIRED (NO EXCEPTIONS)
Instruction Sheet
Please provide copies of the following (NO ORIGINALS)
(Please complete all applicable forms; lack of supporting documentation required will cause a delay in processing or a denial)
*REQUIRED DOCUMENTATION FOR ALL HOUSEHOLD MEMBERS: (NO EXCEPTIONS)
SECTION 1: If you have ONE of these documents, disregard section 2 and 3
U.S. Passport (can be expired)
U.S. American Indian or Alaska Native Tribal Card with photo
Certificate of Naturalization (N-550, N-570), Certificate of U.S. Citizenship (N-560, N-561),
Permanent Resident Card or Resident Alien Card (I-551)
SECTION 2: Must have ONE of these documents
Certified Birth Certificate OR Certificate of Birth Abroad (FS-240, DS-1350, or FS-545)
AND
SECTION 3: Must have ONE of these documents:
• Texas DL or photo ID (can be expired up to 2 years)
• Government Employee ID (city, county, state, or federal)
• U.S. Military or military dependent ID
OR please provide TWO of the following documents
• Social Security Card
• Voter Registration Card
• Medicare or other Health Card
• Student ID
• School Records (Verification of Enrollment, report card)
• Immunization Records
(Please call the office if you do not have the above documentation, other documents may be acceptable)
**If documents requested are not verifiable or legible by GETCAP, you may be asked to provide
additional information**
Example of how to complete the Systematic Alien Verification Form (SAVE).
Household Member Names
U.S. Citizen (Born or
Naturalized) or U.S.
National (Yes/No)
Qualified Alien
(Yes/No)
Documentation Provided for:
Status
Identification
Jane Doe
Yes
No
Birth Certificate
Photo ID
Kim Doe
Yes
No
Passport Card
Student ID &
Immunization Records
John Doe
Yes
No
Early School Record
& U.S. Census
Record
Student ID & Social
Security Card
Note: If you do not have Passport or Birth Certificate & Photo ID, then you will need to provide 2 forms
of proof to prove Citizenship & Identity.
Greater East Texas Community Action Program
Application for Services
ALL FIELDS MUST BE COMPLETED
Energy Assistance
Please check the program you are applying
RIS
E (Case Management)
Weatherization
Head Start
Health Insurance:
(more than one may be chosen)
Education:
A. Medicaid A. 0 – 8 Grade
B. Medicare B. 9 – 12 Grade
C. State Children’s Health Insurance (CHIP) C. High School Graduate or GED
D. State Health Insurance for Adults D. Some College
E. Military Health Care E. 2 or 4 year College Graduate
F. Direct Purchased F. Graduate of other
G. Employment Based Post-Secondary School
H. None
Work Status: Race:
A. Full Time A. Black or African American
B. Part Time B1. Hispanic
C. Migrant, Seasonal or Farm Worker B2. White
D. Unemployed (6 months or less) C. American Indian or Alaskan Native
E. Unemployed (more than 6 months) D. Asian
F. Unemployed (not in Labor Force) E. Multi-race (2 or more)
G. Retired F. Other
ALL FIELDS MUST BE COMPLETED FOR EACH HOUSEHOLD MEMBER
Name of Applicant or Head of Household
Address
City
County
Zip
Mailing Address if Different
Primary Phone #
Secondary or Alternate Phone#
Email Address
Referred By
FIRST & LAST NAME
RELATIONSHIP
TO YOU
Social Security #
Date of
Birth
Sex
Male
Female
ACTIVE
MILITARY
VETERAN
DISABLED
HEALTH
INSURANCE
WORK
STATUS
(18 years or
older only)
EDUCATION
RACE
ETHNICITY
Hispanic or Non
-
Hispanic
1
SELF
2
3
4
5
6
7
separate pageList additional members on back or
FOR OFFICE USE ONLY
Received______________
VA Online Priority ____ _____ ____
F2F N Priority CM ____ ______ ___
Use Legend above to complete
this section
Yes or No
Water Assistance
Rental
Assistance
Other
List all members of household (18 years & over) who work: (I
f paid semi-monthly
, please list pay dates, ex: 5
th
& 20
th
)
NAME
WEEKLY
EVERY 2 WEEKS
SEMI-MONTHLY
MONTHLY
GETS PAID
GETS PAID
GETS PAID
GETS PAID
Does your family receive any of the following benefits
? (Check)
Social Security Retirement
SSI
TANF
VA-Services – Connected
Disability Compensation
Other: Please Explain
Child Support
SSDI
EITC
Worker’s Compensation
Alimony or other Spousal Support
Disability Pension
SNAP
Pension
Unemployment
Insurance
Private Disability Insurance
VA Non-Service Connected
Does your family receive any of the following benefits
? (Check)
WIC Childcare Voucher Public Housing HUD-VASH
Permanent Supportive Housing Housing Choice Voucher Affordable Care Act Subsidy
Please explain what has happened in the past 30 days that has caused you to seek our assistance
and/or a reduction in income:
PART EIGHT- CERTIFICATION/CERTIFICACION
Has this residence ever received services from the Weatherization Program? Yes No When? ______________
Do you OWN or RENT your residence? _What year was your home built? _________________ ____________
If
OWNED
, type of housing? Private Home Mobile Home (Single or Double Wide)
Monthly Mortgage:$ ___________
If
RENTED
, type of housing? Private Home Mobile Home (Single or Double Wide) Apartment
Subsidized Housing Are utilities included in rent? Yes No Monthly Rent: $
______________
Phone#:State: _City:Address: _Landlord Name:_________________ ____________ ______________ ___ ____________
Type of
Air Conditioner
Used: Window Unit Central Unit Evaporative Cooler None
Central Unit or Wall Furnace How many?Type of
Heater
Used: Gas Space Heater ---- _____
Gas or Wood Stove How many? Electric Heater --- _____ ---
In how many rooms is it leaking? Is your roof leaking? Yes No If YES, how long has it been leaking? _____ _____
Are there holes in your floors? Yes No Does your home have a good foundation? Yes No
1. The information provided is true and correct to the best of my knowledge and belief.
La informaci
ó
n proveida en esta forma es correcta seg
ú
n mi major entendimento.
2. My household income has been annualized, at the time of application, according to pre-establising agency
procedures.
Los ingress de mi hogar sido calculados annualmente seg
ú
n los reglamentos preescritos por la agencia.
3. I understand I may request a hearing to appeal a denial of eligibility, amount of assistance received, or a delay of
service delivery.
Comprendo que puedo solicitor una audiencia para apelar decisi
ó
nes que me afectan, tales como: la
eligibilidad al programa, asistencia recibisa o tardanza de asistencia.
4. I authorize the Texas Department of Housing and Community Affairs and it’s contracted agencies to
solicit/verify information on my utility and/ or fuel bills, both past and future, to the extent the information is
used only to provide data.
Autorizo al “Texas Department of Housing and Community Affairs” y sus agencias contratadas a solicitor y
verificar informaci
ó
n sobre mis cuentas pasadas y futuras para luz y gas cuando la informaci
ó
n se usa para
reporter d
á
ta estadistica.
5. I AM AWARE THAT I AM SUBJECT TO PROSECUTION FOR PROVIDING FALSE OR FRAUDULENT
INFORMATION.
COMPRENDO QUE ESTOY SUJETO A SER PROCESADO SI LA INFORMACION ES FALSA O
INCORRECTEA.
PART NINE-ELIGIBILITY DETERMINATION (OFFICE USE ONLY) **DO NOT WRITE BELOW THIS LINE**
Does the household meet the income requirements? Yes No
If no, has the applicant requested a hearing/appeal? Yes No
Does any member of the household fit into the following priority groups:
Elderly Disabled Elderly Disabled Children 5 or under
Recommended Component:
Utility 6 Vulnerable Crisis Weatherization
_______________________________________ _______________________
Signature of Authorized Agency Staff Date
***CASE MANAGEMENT WILL DETERMINE (ON A SEPARATE AGENCY DEVELOPED FORM):
• Appropriate CEAP Component ( Utility 6, Vulnerable, Crisis)
• Benefit Level Determination/Calculations
• Crisis Description/Resolution
• Vendors Paid and Amounts
Referrals/Coordination of Services
You may receive a letter in the mail with a list of payments GETCAP will provide utility assistance for
your household.
No month can be exchanged for any other month.
For any month(s) not listed, GETCAP will not award payment for those months, and you are solely
responsible for your bill.
You must pay your entire utility bill each month, even if you are receiving a pledge through our agency.
All customers are fully responsible for their utility bills.
These payments are not a guarantee based upon funding availability.
All pledges are made on the 3
rd
Friday of Every Month.
It can take up to 45 days for our pledge to post to your account as a payment.
I understand that if I am an Entergy customer, no pledge will be made to my account for the months
stated and I am solely responsible for my bill until payment is received from GETCAP to Entergy.
I acknowledge I have received Energy Saving Tips
Yes
No
Do you have small children who are not in school, if so would you like information
about our Head Start Program?
Yes No
Do you have specific goals that you would like to achieve in the area of
Employment?
Yes No
Do you have specific goals that you would like to achieve in the area of Education?
Yes
No
Do you need help locating your local Child Support Office?
Yes No
Would you like for a representative to contact you about RISE (Reaching
independence through Supportive Elevation Case Management Program)
Yes No
Would you like a representative to contact you about Weatherization?
Yes No
Have you been affected by COVID-19? Yes or No If yes, please explain in the space below.
Date: Applicant Signature: _____________________________ __________________________
Date:Case Manager Signature: _____________________________ _____________________________
TEXAS DEPARTMENT OF HOUSING AND COMMUNITY AFFAIRS
Household Status Verification Form
U.S. Citizen
(Born or Naturalized)
or U.S. National
Qualified
Alien
(Yes/No) (Yes/No)
Citizenship/Qualified Alien Identification
To add additional household members, use another copy of this form.
Date
Date
Systematic Alien Verification for Entitlements (SAVE) System and US Citizenship/US National
Applicant Certification Form for CEAP, DOE-WAP, LIHEAP-WAP Subrecipients, and SHTF, ESG, HHSP, EH (political subdivision only)
Documentation Provided for:
Household Member Name
I AM AWARE THAT I AM SUBJECT TO PROSECUTION FOR PROVIDING FALSE OR FRAUDULANT INFORMATION.
Signature of agency staff certifying they verified the above documents
Print Staff Name
Applicant's Signature
The program for which you are applying requires verification that you are a U.S. citizen, a non-citizen national, or a legal resident of the United States. Documentation
of your status is required. This agency uses the Systematic Alien Verification for Entitlements (SAVE) System to verify the status of non-citizens.
HSV Form: Updated 12/2019 Previous Versions Obsolete
*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 a
ños 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)
$
Last Day of Employment:
Name (Nombre)
Gross Income Received
(Ingreso Bruto Recibido)
$
Last Day of Employment:
Name (Nombre)
Gross Income Received
(Ingreso Bruto Recibido)
$
Last Day of Employment:
Name (Nombre)
Gross Income Received
(Ingreso Bruto Recibido)
$
Last Day of Employment:
Name (Nombre)
Gross Income Received
(Ingreso Bruto Recibido)
$
Last Day of Employment:
Name (Nombre)
Gross Income Received
(Ingreso Bruto Recibido)
$
Last Day of Employment:
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)
GENERAL AUTHORIZATION FOR RELEASE OF INFORMATION
TO WHOM IT MAY CONCERN:
I am an applicant of Greater East Texas Community Action Program.
The information requested is for the purpose of determining my eligibility for assistance and for data
collection.
do hereby authorize the above named agency I, _____________________________________
(Print) Applicant Name
(GETCAP) and its funding sources to obtain all requested information and/or income as needed to determine my
household eligibility for assistance. I understand that this information will be kept in strict confidence and will be used
for program purposes only. Income verification can be from TWC, TDHS, and Social Security Administration, current
and former employers etc... As deemed necessary. Utility usage and income information for data collection purposes
can be requested for up to 90 days.
Note: This release must be signed by the account holder or authorized user.
By checking this box I acknowledge that I am the account holder or authorized user.
By checking this box I acknowledge that I have received a copy of Energy Conservation.
_______________________ __________________________________________
Applicant Signature Date
_______________________ _________________________________________
Address (House # & Street #) SS# only if requesting info
_________________________________________
City, State, & Zip Code (Required Information)
_______________________ __________________________________________
Authorized GETCAP Staff Signature Date
Warning: Section 1001 of the U. S. Code makes it a criminal offense to make willful false statements of misrepresentation to any
Department or Agency of the U. S. as to any within its jurisdiction.
I understand that a photocopy of this release is as valid as the original.
Release to be renewed each calendar year
Now serving 30 counties between Energy Assistance and Weatherization
Electric Company:
Account Number
Account Holder’s Name
Gas Company:
Propane Company:
Other:
I authorize the Texas Department of Housing and Community Affairs and its contracted agency to
solicit/verify information on my energy billing and consumptions histories, both past and future, to the
extent that the information is used only to determine program eligibility and to provide data.
Greater East Texas Community Action Program
AUTHORIZATION TO DISCUSS OR RELEASE CONFIDENTIAL INFORMATION
I, _________________________________, hereby authorize:
(Your Name)
Greater East Texas Community Action, to release any and all information
Relating to my case with the following individuals:
TDHCA (Texas Department of Housing and Community Affairs).
Texas Workforce Office
Texas Department of Health & Human Services.
Texas APS (Adult Protection Services).
Love in The Name of Christ (Love Inc).
Salvation Army
Family Members:
Please List: ________________________ and _________________________
(List 1
st
Family Member) (List 2
nd
Family Member)
Other, please list: ____________________ and _________________________
(Name) (Nature of Relationship)
I DO NOT agree to release my information to anyone.
I further release and hold harmless both Case Manager/Eligibility Specialist and Great
East Texas Community Action Program from any and all liability that may potentially
result from the release and/or use of such information. I understand that an information
released by Greater East Texas Community Action Program will be viewed only by those
involved in case decisions and that neither I nor anyone else not so involved will have the
right to see the information.
__________________________________ _____________________
Signature of Customer Date
Energy Assistance Department
Please Mail, Fax, or Email using the following methods
Applications and all supporting documents may be returned in person, by mail
or email, or by fax.
Mailing address:
P.O. Box 631938, Nacogdoches, TX 75963
(Please include proper postage – mail with insufficient funds will be returned)
Email address: programinfo@get-cap.org
Fax number: 936.564.0302
For updates on your application status please email us at
statusupdate@get- cap.org.
Spanish Version
Las solicitudes y todos los documentos de respaldo se pueden devolver en
persona, por correo postal o electrónico, o por fax.
Direccion de Envio: P.O. Box 631938, Nacogdoches, TX 75963
(Please include proper postage – mail with insufficient funds will be
returned)
Direccion de Correo Electronico: programinfo@get-cap.org
Numero de Fax:: 936.564.0302
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   
    
 
 
    

    
     

     
     
     

 
    
      
    


  
 
      

     

 


    
    
    
    
   



 
   

   
   
    




 
    
    
    
     
    


       
    
     
     

      
 
    
   
 

 

      
     
    
    
     

  
,

f


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