Fillable Utah Community A ction Application for LIHEAP Crisis

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Utah Community A ction Application for LIHEAP Crisis

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The Utah Community A ction Application for LIHEAP Crisis form is 4 pages long and contains:

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  • 16 check-boxes
  • 55 other fields

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Utah
Community A
ction
Application for LIHEAP Crisis Service Call
Soc. Sec. #:
City:
Zip Code: Phone #
E-Mail address: (if you have one)
Service Agreement #
*Applicant’s Name:
Address:
State:
Date of Birth
Dominion Account #
RMP Account
#
Home Ownership:
Yes (Client must provide proof of ownership – County Property Tax Notice, Deed, DMV Title, or Notarized Contract)
See Section C3. 4
No If unit is a rental Crisis Service Call work cannot be done. See Section C3. 5.
(Cooling system repairs also must meet the age/disability test and equipment must include a mechanical problem that
makes replacement necessary.)
Describe Problem:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Date
I hereby give permission to the administering local agency, State of Utah, HEAT, Rocky Mountain Power, and Dominion
Energy to inspect the real property I occupy in order to determine crisis needs, complete the crisis work, and after, to
verify the work and its effectiveness in meeting program goals.
My signature below certifies the information above is correct to the best of my knowledge. In addition it authorizes the
release of income and utility usage records to the administering agency and the State of Utah. I acknowledge that I have
received a copy of the Privacy Act.
03/2020
ATTACHMENT #3
For Office Use Only
Editor Approval Signature Approval Date
The client listed above is eligible to receive Energy Crisis or Weatherization crisis funding from the LIHEAP Program.
Attach copy of HEAT Certificate
FURNACE COOLING SYSTEM WATER HEATER OTHER
Intake Approval Signature Approval Date
Applicant/Guardian Signature
Make:__________________________ Model#:__________________________ Serial#:________________________
850 W 1700 S | SLC, Utah 84104
801-214-3215| weatherization@utahca.org
On File
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Authorization to Release Customer Information to a Third Party Agent
50863 07/18
This is a legal binding contract. This form must be signed by the account holder
or authorized agent for the account holder (such as CFO or City Manager).
Account:
Service Address:
I, __________________________________ of the above referenced account located at _____________________________________
do hereby authorize Questar Gas Company (“Dominion Energy”) to release the designated information below
To _____________________________________________
To _____________________________________________
This authorization provides the right to the designated Third Party Agent to request information regarding the items initialed below:
_______
Billing History (not including payment history or discontinuation of service) and all meter usage data used in the billing
________________calculations_of_the_specied_account
_______ _All_meter_usage_data_relating_to_the_specied_account
_______ _A_copy_of_the_bills_on_the_specied_account_mailed_to_the_third_party
_______ Deliver copies of any notices regarding termination of my natural gas service
This authorization will remain in full force and effect until date of ___________________ . If unspecied, this authorization will be limited
to a one-time request.
I, ____________________________________ declare that:
I am authorized to execute this document on behalf of the account record
__I_have_the_authority_to_nancially_bind_the_Customer_Record
__I_am_granting_the_Third_Party_Agent(s)_listed_above_the_right_to_request_the_release_of_specied_account_information
I understand that Dominion Energy reserves the right to verify any and all information provided pursuant to this authorization before
releasing customer data to the Third Party Agent.
I hereby release, hold harmless, and indemnify Dominion Energy from any liability, claims, demands, and causes of action, damages, or
expenses resulting from: any release of information to the Third Party Agent pursuant to this authorization; the unauthorized use of this
information by the Third Party Agent; and any actions taken by the Third Party Agent pursuant to this authorization.
Customer Signature:
_______________________________________________
Customer Phone Number: ______________________________________ Email: ___________________________________________
Executed this __________________ day of _________________________ , 20 ________ .
I, Third Party Agent, hereby release, hold harmless, and indemnify Dominion Energy from any liability, claims, demands, causes of action,
damages or expenses resulting from the use of customer information obtained pursuant to this authorization and from the taking of any
action pursuant to this authorization.
Third Party Agent Signature: _________________________________________
Third Party Agent Company: _________________________________________
Third Party Agent Phone Number: ________________________________ Email: ___________________________________________
Executed this __________________ day of _________________________ , 20 ________ .
THIRD_PARTY_NAME/COMPANY
THIRD_PARTY_NAME/COMPANY
CUSTOMER_NAME_OR_AUTHORIZED_AGENT ADDRESS
1140 West 200 South | P.O. Box 45360 | Salt Lake City, UT 84145-0360 | 800-323-5517
UCA Weatherization
/ / 2024
✔
✔
Utah Community Action Weatherization
weatherization @utahca.org
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1
Usage and/or Billing History Information Release Form
Return completed forms to:
Email – BillingUsageRequests@pacificorp.com
Mail – Rocky Mountain Power C/O Billing Usage Requests PO Box 25308 Salt Lake City, UT
84125-0308
Fax – 1-800-842-8458
Customer Name:
Address (include apartment, if applicable):
City: State and Zip:
Customer Account Number(s):
Authorizing release of (initial one box only):
Both Usage History and Billing Information – Requestor may request and receive monthly kWh
consumption and billing history for the proceeding 12-month period from the date of each
r
equest.
Billing Information only – Requestor may request and receive billing history for the proceeding
12-month period from the date of each request.
Usage History only – Requestor may request and receive monthly kWh consumption for the
pr
oceeding 12 month period from the date of each request.
Other (Please specify)___________________________________________________________
R
eleased information to be used for (initial all that apply):
HUD utility analysis and/or allowances
Weatherization
Other (Please specify)___________________________________________________________
I (CUSTOMER) AUTHORIZE THE RELEASE OF MY ACCOUNT INFORMATION ON THE
FOLLOWING BASIS* (initial one box only):
One-time authorization only (limited to a one-time request for information specified above
at
the time of receipt of this Authorization).
One year authorization - Requests for information specified above will be accepted and
pr
ocessed each time requested within the twelve-month period from the date of executio
n
of
this Authorization.
Authorization is given for the period commencing with the date of execution until
________
(Limited in duration to three years from the date of execution.)
Requests for information specified above will be accepted and processed each time
req
uested within the authorization period specified herein.
*I
f no duration is specified, authorization
will be limited to a one-time release.
Comments:
801-214-3215
2
CUSTOMER, PLEASE READ BEFORE SIGNING:
• T
he Usage History and/or Billing Information Release Form provides our customers
a
m
echanism to authorize Rocky Mountain Power to share data with specified third parties.
• Rocky Mountain Power is committed to safeguarding customer information. We will not shar
e
c
ustomer account or energy usage data with third parties unless authorized by the customer.
• The attached release form enables Rocky Mountain Power to track the type of informati
on a
customer wishes to share with a third party and for how long.
• Rocky Mountain Power can and will revoke releases upon customer request at any time.
• Any alterations to this authorization form after it’s been executed by the Rocky Mountain Power
customer will render the form null and void.
A
uthorization:
I
(Customer), by signing below authorize PacifiCorp, doing business as Rocky Mountain Power
(“PacifiCorp”), to release kilowatt-hour consumption data and/or billing information corresponding to the
account(s) identified above to the party listed below. I hereby waive any claims against PacifiCorp arising
out of or in any manner related to the release of such consumption, usage, and billing information.
I understand that I may cancel this authorization at any time by submitting a request in writing to
PacifiCorp. Such cancellation will not be valid if action was already taken.
Release Information To:
Customer Signature:
Date:
R
EQUESTOR, PLEASE PRINT ENTITY NAME AND READ BEFORE SIGNING:
____
_____________________________________ (Third Party Requestor), hereby releases, holds
harmless, and indemnifies the Utility from any liability, claims, demand, causes of action, damages, or
expenses resulting from the use of customer information obtained pursuant to this authorization and from
the taking of any action pursuant to this authorization, including rate changes.
Entity / Company
Name:
Signature:
Date:
Title:
Telephone
Number:
Email address:
Utah Community Action Weatherization
Utah Community
Action Weatherization
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Utah Community A ction Application for LIHEAP Crisis

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Completed 8 June 2021

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