Basic
Information
- -
(
)
Applicant's Last Name First Name M.I. Area Code
Applicant's Address: City: State:
RPU CAP
Website:
Utility Account Number: Type of utility service:
Electric Water
Income
Verification
Applicant's
Signature
Energy
Savings
Assistance
Program
Amount of Bill:
Deposit Notice:
Current Assistance:
Current Assistance:
Yes
Monthly:
Yes
No
Yes
No
4. Pensions (Retirement Benefits, Insurance Benefits, Disability Insurance, Workers Comp)
$
5. All other income, specify (Child Support or Alimony, Savings, Investment, Interests, Jury Duty
Pay, Unemployment Insurance)
$
6. No Income
(Please state reason and length of time of no income)
Must provide documentation.
Agency
Approval
Intake Workers Name (Print)
Intake Worker's Signature
Date
TOTAL: $
1. I hereby authorize the Community Action Partnership (CAP) to examine all employment, income, utility, and other
records pertinent to my application for energy assistance.
2. I hereby authorize RPU to release information regarding my bills past and future, to CAP.
3. I certify that I am temporarily unable to pay my energy bill(s).
4. I certify that I am solely or jointly responsible for payment of the utilities for this address.
5. I certify under penalty of perjury that all information herein is true and correct to the best of my knowledge and that I
have read the Privacy Notification.
The information on this application will be used to determine and verify my eligibility for assistance. By signing be
low, I give my
consent (permission) to RPU, its contractors, consultants, other federal, state or local agencies (RPU Partners) and to my utility
company an
d 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.
PLEASE DO NOT WRITE BELOW THIS LINE
AGENCY USE ONLY
Energy Needs
Verification
Danger of Disconnection:
3. SSI/SSP or SSA (Please add, if both benefits ar
e granted)
$
Type of Income (for every member of the household - last 4 weeks) Income
Ages 60 or older (senior)
Disabled
1. Paychecks (Gross salary, wages, benefits, bonus, overtime and net income from self-employed)
$
2. Federal or State Assistance Programs (CalFresh/SNAP, CalWorks/TANF, LIHEAP, Medi-Cal/Medicaid
Healthy Families A&B, National School Lunch Program, SSI, WIC, Bureau of Indian Affairs)
$
Intake Application
Ages 2 - or younger
Utility Service in Name of:
Household Members: (Please include separate sheet for additional household members:
How did you hear about S
HARE?
Friend/Family
Total number of persons living in
household including applicant:
Social Security Number
Riverside CA
Zip Code:
Ages 3 - 5 years
Ages 6 - 17
Ages 18 - 59 (adult)
Applicant's Signature
Date
Applicant's Signature
Date
Witness Signature if Applicable
Phone Number
Name Relationship to Applicant Type of Income Age
Emergency/
Deposit:
Please return completed application and copies of required documents
to one of the following locations:
No
Community Action Partnership
2038 Iowa Ave Suite B-101/B102
Riverside, CA 92507
REV 4/2019
Last Date of SHARE Assistance:
RPU Customer Resource Center
3025 Madison Ave
Riverside, CA 92504
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