Applicant's Last Name First Name M.I. Area Code
Applicant's Address: City: State:
Utility Account Number: Type of utility service:
Amount of Bill:
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.
Intake Workers Name (Print)
Intake Worker's Signature
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
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
Danger of Disconnection:
3. SSI/SSP or SSA (Please add, if both benefits ar
Type of Income (for every member of the household - last 4 weeks) Income
Ages 60 or older (senior)
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)
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
Total number of persons living in
household including applicant:
Social Security Number
Ages 3 - 5 years
Ages 6 - 17
Ages 18 - 59 (adult)
Witness Signature if Applicable
Name Relationship to Applicant Type of Income Age
Please return completed application and copies of required documents
to one of the following locations:
Community Action Partnership
2038 Iowa Ave Suite B-101/B102
Riverside, CA 92507
Last Date of SHARE Assistance:
RPU Customer Resource Center
3025 Madison Ave
Riverside, CA 92504