HOW TO APPLY FOR LiHEAP
STEP 1: FILL OUT
AND SIGN APPLICATION FORMS
HEAP (Utility Bill Assistance)
WEATHERIZATION (Home Repair)
Energy Intake Form
HEAP Forms + Weatherization Forms
Statement of Citizenship
*ADDITIONAL FORMS
Acknowledgment Form
Customer Consent Form
Certification of Income and Expenses
(CSD Form 43B)
PG&E Cares Application
Statement of Financial Support
*As applicable. Additional forms not included with application.
Forms available in the HSA lobby or on the website.
(Optional)
STEP 2: ATTACH
All documents must be current within 30 days of application date.
SUPPORTING DOCUMENTS
(See Document Checklist on the back page for a list of acceptable documents)
ENERGY BILLS
TOTAL GROSS INCOME
US CITIZENSHIP


For ALL household members

For Applicant Only

Adults with zero income? Include form
CSD 43B filled out and signed by each
household member 18+ with no income

Birth Certificate

Certificate of Naturalization

Permanent Resident Card
(Green Card)
All Pages of the Regular
Bill (For all applicants: include
ALL heat source bills, invoices or
receipts for gas, propane & wood)

*Shut-Off? Include PG&E
Account Information Sheet
-or- Notice for City of Lodi
and Modesto Irrigation in
addition to the regular bill

Zero HOUSEHOLD income? CSD 43B +
Statement of Financial Support (filled out
by Applicant) to explain how monthly
living expenses were paid
*Req. for emergency assistance.
STEP 3: SUBMIT
*BY MAIL
BY DROP BOX
FOR *PROCESSING
Energy Program
SJC Human Services Agency
PO Box 201056
HEAP Self-Service Drop Box
Stockton, CA 95201
333 E. Washington Street
*Postage paid envelopes
available.
Stockton, CA 95202
*Please allow 4 to 6 weeks for processing.
PY 2017
OFFICE HOURS
QUESTIONS?
PHONE
WEBSITE
8AM to 5PM
209-468-3988
www.sjchsa.org
PHONE HOURS
9AM to 12PM and 1PM to 4PM
Como Solicitar LiHEAP
PASO 1: LLENAR
Y FIRMAR LOS FORMULARIOS DE SOLICITUD
CLIMATIZACIÓN
HEAP (Asistencia Para Pagar Servicios
Publicos)
(Reparación de Hogar)
Formas HEAP + Formas de Climatización
La Forma de Consumo de Energía
*FORMAS ADICIONALES
Declaración de la Ciudadania
La Forma de Reconocimiento
Certificación de Ingresos y Gastos
(Forma CSD 43B)
El Formulario de Consentimiento
de Cliente
Declaración de Apoyo Financiero
*Segun sea aplicable. Formularios adicionales
no incluidos con la aplicación estan disponibles en el vestibulo de HSA o en sitio web
Solicitud de PG&E Cares (opcional)
PASO 2: INCLUIR
DOCUMENTOS DE APOYO
(Vea Lista de Comprobacion de Documentos en la Ultima Pagina,
Para Una Lista de Documentos Aceptable)
FACTURA DE ENERGÍA
TOTAL DE INGRESES EN BRUTO


Para TODOS los miembros del hogar

Adultos sin ingresos? Incluya la forma
CSD 43B llenada y firmada por cada
miembro del hogar 18+ sin ingresos

Todas las Paginas de la
factura
*Desconectado? Incluya Hoja
de Informacion de Cuenta de
PG&E o Aviso de la Cuidad de
Lodi o de Irrigación de
Modesto, ademas la cuenta
normal.
*Requisito para

asistencia de emergencia
PASO 3: ENVIAR
PARA PROCESAMIENTO
CIUDADANIA
ESTADOUNIDENSE
Hogar con CERO ingresos? CSD 43B +
Declaracion de Apoyo Financiero
(llenado por el solicitante) Para explicar
como cada mes se pagan los gastos
*POR CORREO
-O-

Para Solicitante Solamente

Acta de Nacimiento E.U.

Certificado de Naturalización

Tarjeta de Residente
Permanente (Mica)
BUZON DE HEAP
Programa de Energía
SJC Human Services Agency
PO Box 201056
(HEAP Self-Service Drop Box)
Stockton, CA 95201
333 E. Washington Street
*Sobre Pre-Pagado
Disponible
Stockton, CA 95202
HORAS DE OFICINA
Preguntas?
Telefono
Sitio Web
8AM to 5PM
209-468-3988
www.sjchsa.org
HORAS DE TELEFONO
9AM to 12PM y 1PM to 4PM
San Joaquin County Human Services Agency
LOW INCOME HOME ENERGY ASSISTANCE PROGRAM 2017
(LIHEAP)
ACKNOWLEDGMENT FORM
The San Joaquin County Low Income Home Energy Assistance Program (LIHEAP) is able to assist San
Joaquin County residents with gross household incomes at or below 60% of State Median Income level.
2017 Income Guidelines at 60% of State Median Income (SMI)
1
2
3
4
5
6
7
8
9
10
$2,091.92 $2,735.58 $3,379.25 $4,022.92 $4,666.58 $5,310.25 $5,430.94 $5,551.63 $5,672.31 $5,793.00
NOTE: Income amounts for family sizes greater than six persons were determined based on the following calculation: Add 3% to 132% for each
additional family member, multiply the new percentage by $48,275, and divide by 12.
Example: household size of 7: 132% + 3% = 135% x $48,275 = $65,171.25 / 12 = $5,430.94 per month.
Applicant Responsibilities:
1. Submit an application with complete and correct information.
2. Verify income is at or below 60% of State Median Income level (SEE INCOME GUIDELINES).
3. Verify household composition (by reporting total number of household members).
4. Submit supporting documentation for ALL of the following (SEE DOCUMENATION
CHECKLIST):
 US citizenship or legal residency for applicant only.
 Current total gross income for all members of the household.
 Current energy costs for all energy sources in the home (electric, gas, propane, and wood).
5. Review and keep the Assurance 16 Home Energy Conservation and Home Budgeting Fact Sheets for
your records.
San Joaquin County LIHEAP Responsibilities:
1. Review completed applications and determine qualification based on program criteria.
2. Determine eligibility for benefits based on program guidelines and the agency’s priority
plan approved by the State of California.
3. Assist eligible households by processing applications for “one time” (once per year)
payment of electric/gas or propane utility costs as funds are available.
Applicant Signature
Date
Applicant Name (Print)
Email Address (OPTIONAL)
PO BOX 201056 | STOCKTON, CA 95201
209-468-3988 | Toll Free 1-877-977-3988 | www.sjchsa.org
Department of Community Services and Development
Energy Intake Form
CSD 43 (11/2015)
Agency: SJC Aging & Community Services Intake Initials:
First name
Middle Initial
Official Use Only:
Priority Points
A.C.C.
Eligibility Cert Date
Job Control Code
Intake Date:
Last Name
Date of Birth
MM/DD/YY
Mailing Address
Unit Number
Mailing City
Mailing County
Mailing State
Mailing Zip Code
SERVICE ADDRESS – Address where applicant lives (this cannot be a P.O. Box)
☐ Yes
Have you lived at this residence during each of the past 12 months…………………………………………………………………………………. ☐ Yes
☐ No
☐ No
Is your service address the same as mailing address?............................................................................................................
Service Address
Unit Number
Service City
Service County
Service State
Social Security Number (SSN):
Telephone Number (
Service Zip Code
)
☐Message Only?
E-mail Address (Optional):
PEOPLE LIVING IN HOUSEHOLD
INCOME
Enter the total number
of people living in the
household, including the applicant 
Enter the number of household
members who receive income 
Demographics - Enter the number of people who are:
Enter total gross monthly income for all people living in the household:
Ages 0 – 2 Years
TANF / CalWorks
$
Ages 3 - 5 years
SSI / SSP
$
Ages 6 - 18 years
SSA / SSDI
$
Ages 19 - 59
Paycheck(s)
$
Ages 60 and older
Interest
$
Disabled
Pension
$
Native American
Other
$
Seasonal or Migrant Farmworker
Total Income
$
HOUSEHOLD MEMBERS (Optional)
FULL NAME:
Full name is First Name, Last Name.
For example: husband, daughter, friend, aunt, grandfather, etc.
DATE OF BIRTH: List the date of birth of each household member.
AMOUNT OF MONTHLY GROSS INCOME: “gross” income means the amount of money received before taxes or anything else is taken out.
If you have more than 8 people in your household, you can write the information on a separate piece of paper.
RELATIONSHIP TO THE APPLICANT:
First Name
Last Name
Relation to
Applicant
Date of Birth
MM/DD/YY
Amount of
Monthly Income
Source of Income
Self
Household Total Monthly Gross Income
$
Are you or someone in your household CURRENTLY receiving CalFresh (Food Stamps)?
☐ Yes
☐ No
To which energy bill do you want the LIHEAP benefit to be applied? (Attach copy of most recent bill or receipt)
☐ Natural Gas
☐ Electricity
☐ Wood
☐ Propane
☐ Fuel Oil
☐ Kerosene
☐ Other Fuel
☐ Natural Gas
☐ Electricity
☐ Wood
☐ Propane
☐ Fuel Oil
☐ Kerosene
☐ Other Fuel
List energy company and account number: Company Name: _____________________ Account #: ____________________________
What is the main fuel used to HEAT your home? A main heating source MUST be checked. (Attach copy of most recent bill or receipt)
In addition to your main heating source, do you ever use any of the following to heat your home (you can select more than one):
(Attach copy of most recent bill or receipt)
☐ Natural Gas
☐ Electricity
☐ Wood
☐ Propane
☐ Fuel Oil
☐ Kerosene
☐ Other Fuel
☐ N/A
Energy Bill Information
Check all that apply for each type of energy source for any home energy costs.
NOTE: The questions below are MANDATORY and require a response.
Required: Attach copies of all most recent energy bills and/or receipts. A copy of an electric bill must be included.
ELECTRIC SERVICE
Are your utilities all electric?
☐ Yes ☐ No
_ __ __
Is your electricity shut-off?
☐ Yes ☐ No
Do you have a past due notice?
☐ Yes ☐ No
NATURAL GAS SERVICE
Is your Natural Gas Company the same as
your electric Company?
☐ Yes ☐ No
Is your Natural Gas shut-off?
☐ Yes ☐ No
Do you have a past due notice?
☐ Yes ☐ No
WOOD, PROPANE or FUEL OIL SERVICE
(WPO)
Are you currently out of fuel? (Wood,
Propane, Oil, Kerosene, Other Fuels)
☐ Yes
☐ No
☐ N/A
List the approximate number of days until
you run out of fuel (Wood, Propane, Oil,
Kerosene, Other Fuels).
Number of Days: _____________
☐ Yes
Are your utilities included in rent or submetered?
☐ N/A
☐ No
The information on this application will be used to determine and verify my eligibility for assistance. My signature gives consent for this information
to be shared with other offices of the state and federal governments, their designated subcontractors, my utility company(ies), and for my utility
company(ies) to share my account information with the Department of Community Services and Development (CSD), its designated subcontractors,
and other offices of the state and federal governments for the purpose of providing services to me and to coordinate, improve and reduce the costs
of services under these programs. I further authorize my utility company(ies) to provide my energy consumption data to CSD to the extent necessary
for CSD to comply with the program reporting requirements of the federal government. I understand that this consent shall remain in effect for
three years from the date signed unless otherwise revoked by me in writing. I understand that if my application for LIHEAP/DOE benefits or services
is denied, or if I receive untimely response or unsatisfactory performance, I may initiate a written appeal with the local service provider and my
appeal shall be reviewed no later than 15 days after the appeal is received. If I am not satisfied with the local service provider's decision I may then
appeal to the Department of Community Services and Development pursuant to Title 22, California Code of Regulations section 100805. If
applicable, I hereby authorize installation of weatherization measures to my residence at no cost to me. I declare, under penalty of perjury, that the
information on this application is true, correct, and that the funds received will be used solely for the purpose of paying my energy costs.
X
* * * APPLICANT’S SIGNATURE * * *
Today’s Date
Witness’s Signature (If signed with an X)
AGENCY NAME: Community Services and Development (CSD). UNIT RESPONSIBLE FOR MAINTENANCE: Home Energy Assistance Program (HEAP).
AUTHORITY: Government Code Section 16367.6 (a) Names CSD as the agency responsible for managing HEAP. PURPOSE: The information you
provide will be used to decide if you are eligible for a LIHEAP payment and/or weatherization services. GIVING INFORMATION: This program is
voluntary. If you choose to apply for assistance, you must give all required information. OTHER INFORMATION: CSD uses statistical definitions from
the annual update of the Department of Health and Human Services' State Median Income, Federal Income Poverty Guidelines, to determine
program eligibility. During application processing, CSD's designated subcontractor may need to ask you for more information to decide your
eligibility for either or both programs. ACCESS: CSD's designated subcontractor will keep your completed application and other information, if used,
to determine your eligibility. You have the right to access all records holding information about you. CSD does not discriminate in the provision of
services on the basis of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status,
sex, age, or sexual orientation.
APPLICANT: DO NOT FILL OUT THE INFORMATION BELOW. THIS SECTION IS FOR OFFICIAL USE ONLY.
Utility Assistance being provided under which program  ☐ HEAP ☐ Fast Track ☐ HEAP WPO ☐ ECIP WPO
Supplement $________________ Total Benefit $_______________
☐ Home referred for WX ☐ Home already weatherized
Energy Services Restored after disconnection: ☐ Yes ☐ No
Disconnection of Energy Services prevented: ☐ Yes ☐ No
Type of Dwelling:
☐ MFD – Owner, 2 - 4 units ☐ Mobile Home – Owner ☐ Shelter: # of units _______ ☐ Unoccupied MFD: 2 – 4 units
☐ SFD – Owner, 1 unit
☐ MFD – Rental, 2 - 4 units ☐ Mobile Home - Rental
Total # of residents: _____ ☐ Unoccupied MFD: > 5 units
☐ SFD – Rental, 1 unit
☐ MFD – Owner, 5 or more units
Total Energy Cost:
Energy Burden:
☐ MFD – Rental, 5 or more units
$_________________________
________________________%
Agency Defined Priorities: ☐ Medically Needy ☐ Frail Elderly ☐ Severe Financial Hardship ☐ Hard to Reach ☐ Priority Offsets
☐ N/A
Department of Community Services and Development
Energy Intake Form
CSD 43 (11/2015)
Agency: SJC Aging & Community Services Intake Initials:
Nombre
Inicial
Official Use Only:
Priority Points
A.C.C.
Eligibility Cert Date
Job Control Code
Intake Date:
Apellido
Fecha de Nacimiento
MM/DD/YY
Domicilio Postal
Número de Unidad
Ciudad (de su domicilio postal)
Condado
Estado
Código Postal
Domicilio De Servicio-Domicilio donde vive el aplicante (No use Apartado Postal - P.O. Box)
☐ Sí
Han vivido en esta residencia durante cada uno de los últimos 12 meses …………………………………………………………………………………. ☐ Sí
☐ No
☐ No
Es igual que la domicilio postal?.......................................................................................................................................................
Domicilio de servicio
Número de Unidad
Ciudad
Condado
Estado
Código Postal
Número de Teléfono: (
Only?
Número de Seguro Social (SSN):
☐Mensaje
)
Correo electrónico (opcional):
PERSONAS VIVIENDO EN EL HOGAR
INGRESOS
Escriba el número de
personas que viven en
su hogar , incluyendo al solicitante 
Escriba el número de personas en el
hogar que reciben ingresos
Escriba el total del ingreso mensual, en bruto, de todas las personas que
viven en su hogar:
Introduce el número de personas que son :
De 2 años o menores
De 3 años a 5 años
TANF
SSI / SSP
$
$
De 6 años a 18 años
SSA / SSDI
$
De 19 años a 59 años
De 60 años o mayores
Incapacitados
Sueldo(s)
Interés
Pensión
$
$
$
Americanos Nativos
Otros Ingresos
$
Campesinos Temporales/Migratorios
Ingresos Total
$
MIEMBROS DEL HOGAR (Opcional)
NOMBRE COMPLETO: Su nombre completo es Nombre, Apellido.
RELACIÓN CON EL SOLICITANTE: POR ejemplo: marido, hija, amiga, tía, abuelo, etc.
FECHA DE NACIMIENTO: ANOTE la fecha de nacimiento de cada miembro del hogar.
CANTIDAD DE INGRESO MENSUAL EN BRUTO: “bruto” ingreso significa la cantidad de dinero recibido antes de impuestos o cualquier otra deducción.
Si usted tiene más de 8 personas en su hogar, usted puede escribir la información en una hoja de papel separado.
Nombre
Apellido
Parentesco
con el
Solicitante
Fecha de
Nacimiento
MM/DD/AA
Cantidad de
ingreso mensual
sí mismo
Total de Ingresos Mensuales en Bruto
$
¿Usted o alguien en su casa ACTUALMENTE recibe CalFresh (estampillas de comida)?
☐ Sí
☐ No
Fuente de ingreso
¿A cual factura de energía desea aplicar su beneficio de LIHEAP? (Adjuntar Copia de la Factura o Recibos)
☐ Gas Natural ☐ Electricidad ☐ Madera ☐ Propano ☐ Aceite Combustible ☐ Queroseno ☐ Otro combustible
Lista compañía de energía y número de cuenta: Nombre de la compañía: _____________________ Número de cuenta: ____________________
¿Cuál es el principal combustible que se utiliza para CALENTAR su casa? Una fuente principal de calefacción DEBE estar marcada (Adjuntar Copia de
la Factura o Recibos)
☐ Gas Natural
☐ Electricidad ☐ Madera ☐ Propano ☐ Aceite Combustible ☐ Queroseno ☐ Otro combustible
Además de su fuente principal de calefacción, alguna vez utiliza cualquiera de los siguientes para calentar su casa (usted puede
seleccionar más de uno): (Adjuntar Copia de la Factura o Recibos)
☐ Gas Natural ☐ Electricidad ☐ Madera ☐ Propano ☐ Aceite Combustible ☐ Queroseno ☐ Otro combustible ☐ N/A
Información de su factura de Energía
Marque todas las que apliquen para cada tipo de fuente de energía para los gastos de energía del hogar.
NOTA: Las preguntas siguientes son OBLIGATORIOS y requieren una respuesta
Incluya copias de sus facturas más recientes de energía Y/O recibos (si es aplicable) y adjuntar a esta solicitud
SERVICIO ELÉCTRICO
¿Son sus utilidades todo eléctrico? _
☐ Sí ☐ No
¿Está apagada su electricidad?
☐ Sí ☐ No
¿Tiene actualmente un aviso de pago
atrasado?
☐ Sí ☐ No
SERVICIO DE GAS NATURAL
¿Su Compañía de Electricidad el mismo que
su Compañía de Gas Natural?
☐ Sí ☐ No
_ __ __
¿Está apagado su Gas Natural?
☐Sí ☐ No
¿Tiene actualmente un aviso de pago
atrasado?
☐Sí ☐ No
MADERA, PROPANO or SERVICIO DE
ACEITE CUMBUSTIBLE (WPO)
¿Está usted actualmente sin combustible?
(Madera, Propano, Aceite, queroseno, Otro
Combustible)
☐ Sí
☐ No
☐ N/A
Anote el número aproximado de días hasta
que te quedas sin combustible (Madera,
Propano, Aceite, queroseno, Otro Combustible).
Número de días: _____________
☐ Sí
¿Está su electricidad incluida en la renta o sub-medidos?
☐ N/A
☐ No
La información en esta solicitud será usada para determinar y verificar mi elegibilidad para recibir ayuda. Con mi firma doy autorización para que esta información sea
compartida con otras oficinas del Gobierno Estatal y Federal, subcontratistas designados por ellos, con la(s) compañía(s), que me ofrece(n) servicio(s) de energía y para
que la(s) compañía(s) que me ofrece(n) servicio(s) de energía comparta(n) información con otras oficinas del Gobierno Estatal y Federal con el fin de proporcionar
servicios a mí y a coordinar, mejorar y reducir los costes de servicios bajo estos programas. Además autorizo a mi compañía (s) utilidad para proporcionar mis datos de
consumo de energía a CSD en la medida necesaria para CSD para cumplir con el programa informando los requisitos del gobierno federal. Entiendo que este
consentimiento permanecerá en vigor durante tres años a partir de la fecha de la firma, a menos que sea revocada por mí por escrito. Entiendo que si mi aplicación
para beneficios o servicios de LIHEAP/DOE se niega, o si recibo una respuesta retrasada, puedo iniciar una apelación escrita con el proveedor de servicios local y mi
apelación se revisará no mas que 15 días después de que la apelación se solicita. Si yo no estoy satisfecho con la decisión del proveedor de servicios entonces puedo
apelar al Departamento de Servicios y Desarrollo de la Comunidad (CSD) conforme al Titular 22, Código de California sección 100805. En caso de ser elegible, doy
permiso para la instalación de material aislante en mi residencia sin costo alguno para mí. Declaro, bajo pena de perjurio, que la información declarada en esta solicitud
es correcta y verdadera, y que los fondos recibidos serán usados únicamente con el objetivo de pagar mis gastos de consumo de energía.
X
* * * FIRMA DEL SOLICITANTE * * *
Fecha de hoy
Firma del Testigo (si firmó con una X)
NOMBRE DE LA AGENCIA: Departamento de Servicios y Desarrollo de la Comunidad (CSD). UNIDAD RESPONSABLE DE MANTENIMIENTO: Programa de Ayuda para la
Energía del Hogar (HEAP). AUTORIDAD: El código gubernamental, Sección 16367.6 (a) designa a CSD como la agencia responsable de la administración de HEAP.
OBJETIVO: La información que proporcione se usará para determinar si usted reúne los requisitos para recibir el pago de LIHEAP, y/o servicios de weatherization.
PROPORCIONANDO INFORMACION: La participación en este programa es voluntaria. Si decide solicitar esta ayuda, debe proporcionar toda la información requerida.
INFORMACION ADICIONAL: CSD utiliza definiciones estadísticas de la actualización anual de las Pautas de Ingresos Federales de Pobreza del Departamento de Salud y
Servicios Humanos para determinar la aceptación de una persona en los programas. Durante el trámite de su solicitud, es posible que el subcontratista designado por
CSD necesite pedirle información adicional para determinar si se le puede aceptar en estos u otros programas. ACCESO: El subcontratista designado por CSD se quedará
con su solicitud, y otra información, si se usó para determinar su elegibilidad. Usted tiene derecho de acceso a todos los expedientes que contengan información sobre
usted. CSD no discrimina en los servicios que ofrece debido a raza, religión, credo, color, origen de nacionalidad, incapacidad física, incapacidad mental, condición
médica, estado marital, sexo, edad, o orientación sexual.
SOLICITANTE: NO COMPLETE LA SIGUIENTE INFORMACIÓN. ESTA SECCIÓN ES SÓLO PARA USO OFICIAL.
Utility Assistance being provided under which program  ☐ HEAP ☐ Fast Track ☐ HEAP WPO ☐ ECIP WPO
Supplement $________________ Total Benefit $_______________
☐ Home referred for WX ☐ Home already weatherized
Energy Services Restored after disconnection: ☐ Yes ☐ No
Disconnection of Energy Services prevented: ☐ Yes ☐ No
Type of Dwelling:
☐ MFD – Owner, 2 - 4 units ☐ Mobile Home – Owner ☐ Shelter: # of units _______ ☐ Unoccupied MFD: 2 – 4 units
☐ SFD – Owner, 1 unit
☐ MFD – Rental, 2 - 4 units ☐ Mobile Home - Rental
Total # of residents: _____ ☐ Unoccupied MFD: > 5 units
☐ SFD – Rental, 1 unit
☐ MFD – Owner, 5 or more units
Total Energy Cost:
Energy Burden:
☐ MFD – Rental, 5 or more units
$_________________________
________________________%
Agency Defined Priorities: ☐ Medically Needy ☐ Frail Elderly ☐ Severe Financial Hardship ☐ Hard to Reach ☐ Priority Offsets
☐ N/A
State of California
Page 1 of 2
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 600 (Rev. 3/24/06)
STATEMENT OF CITIZENSHIP or NON-CITIZEN STATUS FOR PUBLIC BENEFITS
Name of the Applicant Requesting Energy Services
Date
Name of Person Acting for Applicant, if any
Relationship to Applicant
Public Benefits To Citizens And Non-Citizens
Citizens and Nationals of the United States who meet all eligibility requirements may receive services under the
Low-Income Home Energy Assistance Program and/or the Department of Energy Low-Income Weatherization
Assistance Program and must fill out Sections A and D.
Non-Citizens who meet all eligibility requirements may receive services under the Low-Income Home Energy
Assistance Program and/or the Department of Energy Low-Income Weatherization Assistance Program and must
complete Sections A, B or C, and D.
Section A: Citizenship/Non-Citizen Status Declaration
1. Is the applicant a citizen or national of the United States?
If the answer to the above question is yes, where was he/she born?
Yes
No
City/State
2. To establish citizenship or naturalization, please submit one of the documents on List A (attached hereto) which
is legible and unaltered to establish proof.
If you are a Citizen or National of the United States, please go directly to Section D .
If you are a Non-Citizen, please complete Section B, or, if applicable, Section C .
Section B: Non-Citizen Status Declaration
Important: Please indicate the applicant's non-citizen status below, and submit documents evidencing such status.
The no citizen status documents listed for each category are the most commonly used documents that the United
States Immigration and Naturalization Service (INS) provides to non-citizens in those categories. You can provide
other acceptable evidence of your non-citizen status even if not listed below.
1. An alien lawfully admitted for permanent residence under the Immigration and Naturalization Act (INA).
Evidence includes:
INS Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”); or
Unexpired Temporary I-551 stamp in foreign passport or on INS Form I-94.
2. An alien who is granted asylum under section 208 of the INA. Evidence includes:
INS Form I-94 annotated with stamp showing grant of asylum under section 208 of the INA;
INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(5)”;
INS Form I-766 (Employment Authorization Document) annotated “A5”;
Grant letter from the Asylum Office of INS; or
Order of an immigration judge granting asylum.
3. A refugee admitted to the United States under section 207 of the INA. Evidence includes:
INS Form I-94 annotated with stamp showing admission under section 207 of the INA;
INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”;
INS Form I-766 (Employment Authorization Document) annotated “A3”; or
INS Form I-571 (Refugee Travel Document)
4. An alien paroled into the United States for at least one year under section 212(d)(5) of the INA. Evidence
includes:
INS Form I-94 with stamp showing admission for at least one year under section 212(d)(5) of the INA.
(Applicant cannot aggregate periods of admission for less than one year to meet the one-year requirement.)
CSD 600 (Rev. 3/24/06)
Page 2 of 2
5. An alien whose deportation is being withheld under section 243(h) of the INA (as in effect prior to April 1,
1997) or section 241(b)(3) of such Act (as amended by section 305(a) of division C of Public Law 104-208).
Evidence includes:
INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(10)”;
INS Form I-766 (Employment Authorization Document) annotated “A10”; or
Order from an immigration judge showing deportation withheld under section 243(h) of the INA as in
effect prior to April 1, 1997, or removal withheld under section 241(b)(3) of the INA.
6. An alien who is granted conditional entry under section 203(a)(7) of the INA as in effect prior to April 1, 1980.
Evidence includes:
INS Form I-94 with stamp showing admission under section 203(a)(7) of the INA;
INS Form I-688B (Employment Authorization Card) annotated “274a.12(a)(3)”; or
INS Form I-766 (Employment Authorization Document) annotated “A3.”
7. An alien who is a Cuban or Haitian entrant (as defined in section 501(e) of the Refugee Education Assistance
Act of 1980). Evidence includes:
INS Form I-551 (Alien Registration Receipt Card, commonly known as a “green card”) with the code
CU6, CU7, or CH6;
Unexpired temporary I-551 stamp in foreign passport or on INS Form I-94 with the code CU6 or CU7; or
INS Form I-94 with stamp showing parole as “Cuban/Haitian Entrant” under section 212(d)(5) of the
INA; or paroled after 10/10/80 in the special status for nationals of Cuba or Haiti.
8. An alien paroled into the United States for less than one year under section 212(d)(5) of the INA. (Evidence
includes INS Form I-94 showing this status.)
9. An alien not in categories 1 through 8 who has been admitted to the United States for a limited period of time
(a nonimmigrant). Non-immigrants are persons who have temporary status for a specific purpose. (Evidence
includes INS Form I-94 showing this status.)
10. I self-certify that I am a U.S. citizen or non-citizen national or qualified alien but am unable to provide
documentation. (Only allowable under the Energy Crisis Intervention Program (ECIP) component of the
LIHEAP Program.)
Section C: Declaration for Certain Battered Aliens
Important: Complete this section if the applicant, the applicant's child, or the applicant child’s parent has been
battered or subjected to extreme cruelty in the United States by a spouse or parent.
1. Has the INS or the EOIR granted a petition or application filed by or on behalf of the applicant, the
applicant’s child, or the applicant child’s parent under the INA or found that a pending petition sets forth a
prima facie case for granting permission to stay in the United States? Evidence includes one of the
documents on List B (attached hereto).
2. Has the applicant, the applicant's child, or the applicant child’s parent been battered or subjected to extreme
cruelty in the United States by a spouse or parent, or by a spouse's or parent's family member living in the
same house (where the spouse or parent consented to or acquiesced in the battery or cruelty)?
Section D: Certification
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT THE
ANSWERS I HAVE GIVEN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Applicant's Signature
Date
Signature of Person Acting for Applicant
Attachments: Lists A and B
Date
CLIENT/CUSTOMER CONSENT FORM AND AUTHORIZATION
The California Department of Community Services and Development (CSD) is a state
agency that oversees energy assistance programs for low-income families. Some of
these services include helping families pay their utility bills or installing energy-efficient
appliances and systems to reduce energy use and expenses. CSD also works with other
organizations and programs that provide related services.
CONSENT (What you are agreeing to when you sign this form)
By signing this form, you give your 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 household’s utility account,
energy usage and/or other information needed to provide the services and benefits to you described on the back of this form.
1. NAME(S) AND MAILING ADDRESS
Your Name
If your utility bill is in someone else’s name, enter that name here
Your mailing address (Street)
Unit Number (if any)
Your mailing address (City)
State
Zip Code
2. UTILITY SERVICE ADDRESS
 Check here if your utility service address is different from your mailing address.
If you checked the box, please provide your utility service address information below:
Your Utility Service Address (Street)
Unit Number (if any)
Your Utility Service Address (City)
State
Zip Code
CA
3. 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
(If client applying for services is not the person whose name is on the account (i.e., the utility customer of record),
both persons must initial and sign this form)
By initialing and signing below, I acknowledge and authorize my utility company, CSD, and CSD Partners to release upon
request and/or to receive my information as described, exclusively for the purposes stated in this Authorization for up to 36
months unless revoked as explained on the back of this form:
Client/Customer Initials
Utility company billing records: account name, service address, billing history and account
balances, as needed for processing utility bill assistance and emergency payments.
Client/Customer Initials
1) Meter usage and energy consumption data, including up to 12 months of historical data prior to
the date of my signature below; and 2) any information concerning prior weatherization of dwelling
(if weatherized, date and measures installed).
Client/Customer Initials
Household income, composition and other information needed to determine my eligibility for
energy assistance programs administered by CSD and/or CSD Partners.
Signature of Client/Utility Customer
Name of CSD Contractor/Partner Organization
Date
Signature of Utility Customer of Record (if different)
Date
Signature of 2nd Utility Customer of Record, if applicable
Date
SJC AGING & COMMUNITY SERVICES
CSD Form 081 (NEW 5-15)
Page 1 of 2
WHY CONSENT IS NEEDED AND HOW THE INFORMATION WILL BE USED
Your consent (permission) for us to obtain and share your utility information, including your energy usage data, is
needed for the purposes listed and explained below. CSD, its contractors, consultants, other federal or state
agencies and affiliated programs (CSD Partners), working cooperatively with your utility company and its
contractors, can provide you with services and benefits available under various programs administered by CSD and
your utility companies. The information provided will be shared and retained in accordance with applicable law
concerning data security and privacy protections. The information you authorize us to obtain and share will be
used for the following purposes:
1. Determine your eligibility for CSD and utility company low-income programs
2. Protect the security of your information and make it easier for you to apply for/receive services by limiting
the number of times you must provide the same information about yourself and your household, your
residence, income, utility account(s), energy costs and energy usage
3. Determine which services, benefits and assistance you are qualified to receive, including: payment
assistance with your utility bills; weatherization services; energy efficiency services; emergency energy
services; health and safety measures; solar energy services; consumer information and energy tips
4. Evaluate your home’s energy usage 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.
You understand that some services may not be available to you unless you consent to share/release information as
stated in this Authorization. You agree that this consent covers utility account, billing and usage information,
including up to twelve months of historical data prior to the date of this Authorization, information about any prior
weatherization services provided, and subsequent data throughout the period that this Authorization is in effect.
CSD and CSD Partners agree to access and share only the information and data necessary to provide energy
assistance services for which you are determined eligible, and to fulfill state and federal requirements for operating
these programs. If you are determined not to be eligible for services, no utility information will be accessed or
exchanged. CSD and CSD Partners will safeguard your privacy and will store any information gathered in
accordance with the security requirements set forth in state law.
REVOCATION OF 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.
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
CSD Form 081 (NEW 5-15)
Page 2 of 2
FORMULARIO DE CONSENTIMIENTO Y AUTORIZACIÓN DEL
CLIENTE/CONSUMIDOR
El Departamento de Servicios Comunitarios y Desarrollo de California (CSD) es una oficina
estatal que supervisa los programas de asistencia energética para familias de bajos ingresos.
Algunos de los servicios que ofrece consisten en ayudar a las familias a pagar sus facturas de
servicios públicos o en instalar electrodomésticos, artefactos y sistemas de bajo consumo para
reducir el consumo de energía y los gastos que este ocasiona. A su vez, el CSD trabaja en
conjunto con otras organizaciones y otros programas que ofrecen servicios afines.
CONSENTIMIENTO (Lo que acepta al firmar este formulario)
Al firmar este formulario, usted presta su consentimiento (autorización) para que tanto el CSD, sus agentes, asesores, otras
agencias federales y estatales (Asociados de CSD), como la empresa proveedora de servicios públicos y sus agentes,
compartan información sobre las cuentas de servicios de su hogar, el consumo de energía, o cualquier otra información necesaria
para otorgarle los servicios y beneficios que se describen en el reverso de este formulario.
1. NOMBRE(S) Y DIRECCIÓN POSTAL
Su nombre
Si el nombre en su factura es diferente, escriba el nombre aquí.
Su dirección postal (Calle)
Número de unidad
Si corresponde
Su dirección postal (Ciudad)
Estado
Código Postal
2. DIRECCIÓN DONDE RECIBE LOS SERVICIOS
 Marque este casillero si la dirección donde recibe los servicios difiere de la dirección postal.
Si marcó el casillero, por favor proporcione la dirección donde recibe los servicios en el siguiente cuadro:
Dirección donde recibe los servicios (Calle)
Número de unidad
Si corresponde
Dirección donde recibe los servicios (Ciudad)
Estado
Código Postal
CA
3. INFORMACIÓN DE LOS SERVICIOS PÚBLICOS
Por favor proporcione el nombre de la empresa que le provee los servicios públicos y su número de cuenta en el siguiente cuadro
(puede encontrar este número en su factura ). Si el servicio de gas y electricidad no es administrado por la misma empresa, escriba
el nombre de la empresa y el número de cuenta correspondiente para cada servicio:
Proveedor de servicios públicos
Número de cuenta
Proveedor de servicios públicos (si tiene más de uno)
Número de cuenta
AUTORIZACIÓN
(Si el cliente que firma la solicitud no es la persona que figura como titular de la cuenta en los registros, ambos deberán
incluir sus iniciales y firmar el formulario)
Entiendo que al inicialar y firmar este formulario autorizo a mi proveedor de servicios públicos, al CSD y a sus asociados a liberar mi
información cuando así se solicita o recibirla según se detalla, por un período de 36 meses y exclusivamente a los efectos listados
en esta autorización, a menos que se revocara esta autorización según lo dispuesto en el reverso de este formulario:
Iniciales del Cliente
Historial de facturación de la empresa de servicios públicos: titular de la cuenta, dirección del servicio,
antecedentes de facturación y saldos de la cuenta según se requiera para el procesamiento de pagos
de emergencia y asistencia para el pago de la factura de servicios públicos.
Iniciales del Cliente
1) Datos registrados en el medidor y datos sobre el consumo de energía, incluyendo la información
correspondiente a los 12 meses previos a la fecha de mi firma de este formulario; y 2) toda la
información relacionada con la protección de la vivienda contra las inclemencias del tiempo (si la
vivienda estuviera protegida, indicar la fecha y las medidas implementadas).
Iniciales del Cliente
Ingresos familiares, composición familiar y cualquier otra información necesaria para determinar mi
derecho a recibir asistencia energética a través de los programas del CSD o sus Asociados.
Firma del cliente/Titular del servicio
Fecha
Firma del cliente en la factura de servicios (si fuera distinto del que
completa la solicitud)
Nombre del agente del CSD/Organización Asociada
Fecha
Firma del agente del CSD/Organización Representante
Fecha
SJC AGING & COMMUNITY SERVICES
CSD Formulario 081 (NUEVO 5-15)
Página 1 de 2
POR QUÉ NECESITAMOS SU CONSENTIMIENTO Y CÓMO SE UTILIZARÁ SU INFORMACIÓN
Es necesario que preste su consentimiento (autorización) para que obtengamos y liberemos la información relacionada
con sus servicios públicos, incluida la información relacionada a su consumo de energía, por las razones que se indican a
continuación. El CSD, sus agentes, asesores, otras oficinas federales y estatales y los programas asociados (Asociados
del CSD), trabajan junto con su empresa de servicios públicos y los agentes de ésta para ofrecerle los servicios y
beneficios que brindan varios de los programas administrados por el CSD y su empresa de servicios públicos. La
información suministrada se conservará y se liberará de conformidad con las leyes sobre privacidad y protección de datos.
Utilizaremos la información que nos autorice a obtener y compartir con los siguientes propósitos:
1. Determinar si reúne los requisitos para acceder a los programas para familias de bajos ingresos que ofrecen el
CSD y los proveedores de servicios públicos.
2. Resguardar la seguridad de su información y facilitar el proceso de solicitud/otorgamiento de servicios al restringir
la cantidad de veces en las que tiene que brindar la misma información acerca de usted y su hogar, su residencia,
sus ingresos, su(s) cuenta(s) de servicios públicos, sus gastos por consumo de energía y datos sobre el consumo
de energía en su hogar.
3. Determinar qué servicios, beneficios y tipo de asistencia tiene derecho a recibir, incluyendo: asistencia económica
en el pago de sus facturas de servicios públicos; servicios de protección de la vivienda contra las inclemencias del
tiempo; servicios de aprovechamiento de energía eléctrica; servicios de energía de emergencia; medidas de
seguridad y salud; servicios de energía solar; información para el consumidor y sugerencias para el consumo de
energía.
4. Evaluar el consumo de energía en su hogar, de modo que el CSD pueda: a) determinar la reducción en el monto
de las facturas de servicios públicos y la medida en que nuestros servicios logran reducir las emisiones de
carbono (contaminación atmosférica), lo que nos permitirá medir la eficacia de los servicios que brindamos, y b)
reportar estos resultados a las autoridades federales y estatales que financian y supervisan los programas de
asistencia energética en California.
Usted entiende que es posible que algunos servicios no estén disponibles para usted a menos que preste su
consentimiento para compartir/liberar cierta información según se detalla en esta Autorización. Entiende que el
consentimiento que presta abarcará su cuenta de servicios públicos, información de facturación y de consumo de los
últimos 12 meses, información sobre servicios de protección de la vivienda contra las inclemencias del clima que hubiera
contratado en el pasado, así como información nueva que surja durante el período de vigencia de esta Autorización.
El CSD y sus Asociados se comprometen a acceder y compartir sólo la información y los datos necesarios para ofrecer
servicios de asistencia energética a los clientes elegibles y a cumplir con las disposiciones federales y estatales que
regulan la puesta en marcha de estos programas. Si se determina que usted no reúne los requisitos para recibir nuestros
servicios, no compartiremos ni accederemos a la información relacionada con sus servicios públicos. El CSD y sus
Asociados protegerán su privacidad y conservarán toda la información recopilada de conformidad con los requisitos
establecidos en las leyes estatales.
REVOCACIÓN DEL CONSENTIMIENTO
Por medio de la presente, declaro estar de acuerdo con que el período de vigencia de esta autorización sea de 36 meses
corridos desde la fecha de su suscripción, salvo que revoque mi consentimiento por escrito y envíe la documentación a tal
efecto por correo a: CSD Energy & Environmental Services Division, 2389 Gateway Oaks Drive, Suite 100, Sacramento,
CA 95833. La revocación será efectiva a partir de su recepción por parte del CSD pero no afectará la información que se
haya compartido durante el período de vigencia de esta autorización.
PROGRAMAS
A continuación se detallan algunos de los programas que el CSD supervisa o a los que está asociado:
- Programa Federal de Asistencia para Energía para Hogares de Bajos Recursos (LIHEAP)
- Programa de Asistencia de Climatización del Departamento de Energía de los Estados Unidos (DOE WAP)
- Programa Estatal de Climatización para Hogares de Bajos Ingresos (LIWP)
- Programa de Hogares Saludables y Control de Peligros del Departamento de Vivienda y Desarrollo Urbano (HUD)
- Asistencia para el Ahorro de Energía (ESA)
- Programa de Tarifas Alternativas para Energía de California (CARE)
CSD Formulario 081 (NUEVO 5-15)
Página 2 de 2
CARE/FERA PROGRAM APPLICATION
Form 79-1051
Residential Customers
Save 30%* or more on your monthly PG&E bill
The way Californians are charged for energy is changing. Learn more†.
California Alternate Rates for Energy (CARE)
pge.com/care • 1-866-743-2273
The CARE Program offers a monthly discount on
PG&E bills for qualifying households. You can enroll by:
• Checking all the qualifying public assistance
programs from which you, or someone in
your household, receive benefits OR
• Checking the box that matches your household’s
total gross annual income.**
Other qualifications include:
• Your monthly electric usage does not exceed six
times the Tier 1 allowance.
• You are not claimed as a dependent on another
person’s income tax return other than your spouse.
• You do not share an energy meter with another home.
• You will renew your eligibility at least every two years.
Family Electric Rate
Assistance (FERA)
pge.com/fera
1-800-743-5000
If you do not qualify for the
CARE Program, you may
still qualify for the FERA
Program, which offers a
monthly discount on electric
bills for households of
three or more people with
a slightly higher income
than required for CARE.
See the FERA Income
Guidelines listed here to
find out if you qualify, and
enroll by completing the
included application.
*Gas and electricity CARE customers can save at least 30 percent while gas-only CARE
customers can save at least 20 percent.
†Learn more about rate changes at pge.com/ratechanges
How You Can Apply
Online: Apply online for
faster enrollment at
pge.com/care
Phone: Apply by calling
1-866-743-2273
Email: Take a picture or
scan completed application
and email this image to
[email protected]
Fax: Send completed
application to
1-877-302-7563
Mail: Send completed
application to
CARE/FERA Program
P.O. Box 7979
San Francisco, CA
94120–7979
Speech or hearing impaired? TDD/TTY is available at 1-800-652-4712
(9 a.m. to 11 p.m., Monday–Friday). Can’t use the TDD line? Call 1-800-735-2929.
CARE/FERA Income Guidelines (good until May 31, 2017)
Total Gross Annual Household Income**
Number of People
in Household
CARE
FERA
1-2
$32,040 or less
Not Eligible
3
$40,320 or less
$40,321–$50,400
4
$48,600 or less
$48,601–$60,750
5
$56,880 or less
$56,881–$71,100
6
$65,160 or less
$65,161–$81,450
7
$73,460 or less
$73,461–$91,825
8
$81,780 or less
$81,781–$102,225
$8,320
$8,320–$10,400
Each Additional Person, add
**Total gross annual household income includes all taxable and nontaxable revenues from
all people living in the home, from whatever sources derived, including, but not limited to,
wages, salaries, interest, dividends, spousal and child support payments, public assistance
payments, Social Security and pensions, housing and military subsidies, rental income,
income from self-employment and all employment-related, non-cash income.
Other Helpful Programs and Services
Energy Savings Assistance Program
pge.com/energysavings
1-800-989-9744
This program provides energy-efficient
home improvements and appliances at
no cost to customers who qualify for CARE
and rent or own a home that is at least five
years old.
My Account • pge.com/myaccount
Log in to My Account to sign up for billing and
payment alerts, analyze your household’s
energy usage, pay your bills and learn more
about your rate plan options.
Balanced Payment Plan
pge.com/balancedpayment
1-800-743-5000
Your monthly bill will be averaged out to
allow you to budget your energy costs and
eliminate big payment swings.
Medical Baseline
pge.com/medicalbaseline
If you depend on life-support or other
equipment due to medical needs, you may be
eligible for additional energy at the lowest
price through the Medical Baseline Program.
Low Income Home Energy Assistance
Program (LIHEAP) • 1-866-675-6623
If you spend a high percentage of your income
on energy bills, you may be eligible to receive
financial assistance and weatherproofing
services through this program administered
by the California Department of Community
Services and Development.
Universal Lifeline Telephone Service
(ULTS)
Get discounted telephone access when you
meet similar income guidelines as the CARE
Program. To learn more, contact your local
phone service provider.
“PG&E” refers to Pacific Gas and Electric Company, a subsidiary of PG&E Corporation. ©2016 Pacific Gas and Electric Company. All rights reserved.
These offerings are funded by California utility customers and administered by PG&E under the auspices of the California Public Utilities Commission.
Rev. 5.16
Form 79-1051
CARE/FERA PROGRAM APPLICATION
Residential Customers
Please fill out the information below about you and your household, and then
the information for EITHER Section 2A OR 2B. Sign and date this form and return
it to PG&E as soon as possible. If you qualify, your CARE or FERA discount will
appear on the first page of your next PG&E bill.
1
You and Your Household
–
Your PG&E Account Number (Find yours on page 1 of your PG&E bill.)
Your Name
(Use the name as it appears on your PG&E bill, which must be in your name.)
Your Home Address
(Address must be your primary residence. Do NOT use a P.O. Box.)
Unit#
Complete, cut off and return application to PG&E.
City/State/Zip Code
Email Address
(By entering your email address, you are authorizing PG&E to send you
information from time to time regarding your PG&E utility service and PG&E
programs and services that may be available to you.)
Preferred Phone Number
Home
Work
Mobile
Alternative Phone Number
Home
Work
Mobile
What language do you prefer for future CARE and FERA communications?
(Choose one)
English
Spanish
Mandarin
Cantonese
Vietnamese
Russian
Korean
Tagalog
Hmong
What is your preferred method of communication? (Choose one)
Mail
Email
Phone
Text (Message and data rates may apply.)
Number of people in your household at this address:
Adults
+ Children (under 18)
=
2
Household Qualification
Fill out Section 2A OR Section 2B. You do not need to complete both sections.
You will be enrolled in either the CARE or the FERA Program, depending
on your household income and household size.
2A Public Assistance Programs: Check all the programs in which you, or
someone in your household, participate.
Medi-Cal for Families
Low Income Home Energy
(Healthy Families A&B)
Assistance Program (LIHEAP)
National School Lunch
Women, Infants, and Children (WIC)
Program (NSLP)
CalFresh/SNAP (Food stamps)
Bureau of Indian Affairs
CalWORKs (TANF) or Tribal TANF
Head Start Income Eligible (Tribal only) General Assistance
Medicaid/Medi-Cal (under age 65)
Supplemental Security Income (SSI)
Medicaid/Medi-Cal (age 65 and over)
If you checked any of the boxes in this section, skip to Section 3.
OR
2B Household Income
If you did not check any of the boxes in Section 2A, please add up all the
income from every household member and check the box below that matches
your household’s total annual gross income. Please note: The income ranges
listed below ARE NOT fixed incremental amounts, so carefully review each
income range before selecting the appropriate box.
I am currently on a fixed income and receive income or benefits from one or
more of the following: pensions, Social Security, SSP or SSDI, interest/dividends
from retirement accounts, Medicaid/Medi-Cal (age 65 and over) or SSI.
My household income is:
$0–$32,040
$32,041–$40,320
$40,321–$48,600
$48,601–$50,400
$50,401–$56,880
$56,881–$60,750
$60,751–$65,160
$65,161–$71,100
$71,101–$73,460
$73,461–$81,450
$81,451–$81,780
$81,781–$90,100
$90,101–$91,825
$91,826–$98,420
$98,421–$102,225
Other $
3
Your Declaration
By signing this declaration, I certify that based on my household size
and income I qualify for either the CARE or the FERA Program.
I acknowledge that I have read
and understood the contents of
this application, and will have the
opportunity to ask questions at
any time.
I also agree to the following program
terms and conditions in order to
remain eligible for the CARE or the
FERA Program:
1. I will notify PG&E if my household
is no longer eligible for the CARE
or FERA discount.
2. I understand I may be required to
provide proof of household income
and to participate in the Energy
Savings Assistance Program.
X
Customer Signature
Fill in circle if you are a guardian
or you have power of attorney.
3. I will allow PG&E to share my
information with other utilities
or their agents, for the sole
purpose of facilitating enrollment
in their assistance programs.
4. I will pay back the discount if
any of the information provided
above is untrue.
5. The information I have provided
here is true and correct.
Date
FOR INTERNAL USE ONLY
440
K
L
Lower your
Energy Bill for...
San Joaquin County’s
Weatherization Program
provides these services
at no cost to renters or homeowners who qualify.








Repair or replacement of
refrigerator, microwave, & stoves
Heating/Air Conditioning repair or
replacement
Insulation
Water Heater repair or replacement
Ceiling fan installation
Door repair or replacement
Shower heads
Digital Thermostats





Weather-stripping
LED Bulbs
Window (glass only) repair or
replacement
Shade screens
Smoke & Carbon Monoxide
Detectors
Check the chart below to see
if you qualify for this free service:
2017 Income Guidelines
OME
YOUR H SLY
F
I
N
E
EV
IOU
N PREV YOU
E
E
B
S
,
HA
ERIZED
WEATH BE ELIGIBLE
ILL
MAY ST SERVICES!
FOR
# People
in Home*
Annual
Income
Monthly
Income
1
$25,103
$2,091.92
2
$32,827
$2,735.58
3
$40,551
$3,379.25
4
$48,275
$4,022.92
*For households with more than 4 people, please call.
For more information, call 209-468-0439.
Reduzca su Factura
de Energia por...
!
A
R
¡GRATIS!
I
¡M
Programa de Climatizacion
del Condado de San Joaquin
Proporciona estos Servicios
Sin costo para inquilinos o duenos
de viviendas que califican.








Reparacion o reemplazo de
refrigerador, microondas, estufas
Reparacion o reemplazo del
Calefaccion/Aire acondicionado
Aislamento termico
Reparacion o reemplazo del
calentador de agua
Instalacion ventilador de techo
Reparacion o reemplazo de puerta
Cabezales de ducha
Termostato digital





Burletes
Bombillas LED
Reparacion o reemplazo de ventana
(solo cristal)
Detectores de monoxide de carbon y
humo
Pantallas de sombra
Consulte la tabla de abajo pare ver si usted
califica para este servicio gratuito
2017 Requisitos de Ingresos
a
asa se h
c
u
s
i
s
Incluso climatado
a
ted
ente, usser
m
a
i
v
e
r
p
puede
todaviale para los
elegib vicios!
ser
# Personas
en el hogar*
Ingreso
Anuale
Ingreso
Mensuale
1
$25,103
$2,091.92
2
$32,827
$2,735.58
3
$40,551
$3,379.25
4
$48,275
$4,022.92
*Hogares con mas de 4 personas, por favor llame.
Para Mas Informacion, llame 209-468-0439.
WEATHERIZATION FORM
SAN JOAQUIN COUNTY
Weatherization Program
Intake Date:
ST Job#:
DWELLING INFORMATION
Applicant Name:
Applicant Phone Number (s): Home:
Address of Dwelling:
FOR STAFF USE ONLY:
Mobile/Cell:
No. People in Household:
The home to be weatherized is a:
HOUSE
*DUPLEX
*3 - 4 PLEX
*Single level dwellings only. No townhomes, condominiums, or apartments.
Owner Occupied?
MOBILE HOME
Yes_____ No_____
If yes, title is recorded in the name of:
*NOTE: If this home is currently for sale or in foreclosure, weatherization services cannot be provided.
Rented or Leased?
Yes_____ No_____
If yes, please provide landlord name, address, and phone number:
*NOTE: If you are renting your landlord will need to fill out the Energy Service Agreement Form (attached).
Has this dwelling been weatherized before? Yes_____ No_____
If yes, Name of Agency:__________________________________________________(YEAR) _______
Year Built (if known): _________
The exterior siding of the home is: Brick___ Wood___ Stucco___ Aluminum___ Other: __________________
Heat Fuel: Gas___ Propane___ Electric___ Wood___
Cooking: Gas___ Propane___ Electric___
Heating Type: Central Heat___ Window/Wall___ Portable Device___ None___ Other:___________________
Working? Yes_____ No_____
Water Heater Type: Gas___ Electric___ Working? Yes_____ No_____
Cooling Type: Central AC___ Window/Wall AC___ Fans___ Portable Device___ None___ Other:__________
Working? Yes_____ No_____
WEATHERIZATION FORM
MICHAEL MILLER, Director
CHRIS WOODS, Assistant Director
CalWORKs
CalFresh
Medi-Cal
Children’s Services
Mary Graham Children’s Shelter
First 5 San Joaquin
Aging and Community Services
SAN JOAQUIN COUNTY
P.O. Box 201056
102 South San Joaquin Street
Stockton, CA 95201-3006
Aging and Community Services
Tel (209) 468-2202
Fax (209) 468-2207
CONDITIONS OF WORK
The following conditions must be met before any work on your dwelling can begin. Failure to
abide by these conditions may be cause for denial of weatherization services.
 Client is required to be available by telephone until work/inspection is completed.
 Home must be clean.
 Home must have suitable access to outside area for trucks and other equipment.
 Area around attic access must be removed.
 Items stored in attic must be removed.
 Roof must not have water leaks.
 Yard must be free of debris.
 Children must be kept out of equipment and workers’ way.
 All dogs must be restrained and kept away from work area at all times.
 An adult 18 years old or older must be present at all times while work is being performed.
 Clients must allow for mandated inspection of residence.
 Agency is not responsible for any damages to personal items in normal course of work if the
above requirements are not met.
I agree to the above stated conditions and understand that weatherization of my home may
not be completed if these conditions are not met.
Print Client Name
Client Signature
Date
Print Client Address
Assessor’s Signature
Date
Our Mission is to lead in the
creation and delivery of services that improve
the quality of life for our community.
WEATHERIZATION FORM
STATE OF CALIFORINA
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 515A (Rev. 2/12/16)
ENERGY SERVICE AGREEMENT FOR OCCUPANT
Dwelling Information
Select the Dwelling Type
Single-Family
I am the
Mobile Home
Multi-Unit
Owner-Occupant
Tenant
Owner-Occupant or Tenant Information
Owner-Occupant or Tenant (Print or type name)
Address
Apt./Unit No.
ZIP Code
City
Owner-Occupant or Tenant Email Address
Telephone Number
Owner-Occupant or Tenant FAX Number
Owner-Occupant or Tenant Acceptance of Terms for CSD Weatherization Services
(to be completed by the Owner-Occupant or Tenant)
I agree to accept the following TERMS required for my primary residence to receive services from the Department of Community Services and
Development (CSD) weatherization programs(s):
1. I certify that the above-listed property is my primary residence.
2. I (the Owner-Occupant or Tenant), grant the Contractor/Agency permission to enter my dwelling to perform assessments, conduct diagnostics, take
photos only of weatherization work to be performed or deferred (as it relates to individual or whole house services), install feasible weatherization
services and perform inspections in accordance with CSD weatherization program policies and standards to the above-listed dwelling.
3. I acknowledge that an assessment of my dwelling is necessary to determine the work that can be performed and that the work that is available may
be limited due to the needs and condition of my residence. Identified work may not be provided if it does not meet all program requirements and
specifications and may lead to full or partial deferral of work. My refusal of certain work may prevent the installation of other identified work in
accordance to program requirements.
4. I hereby release and pledge to hold harmless the Contractor/Agency listed below, and its staff, from any liability in connection with the work
identified on a summarized list, except as a consequence of gross negligence or willful and wanton misconduct.
5. I authorize the Contractor/Agency to access my utility company records to obtain only energy usage data for a period of one year before and two
years after weatherization measures are installed.
6. I grant the Contractor/Agency, local, State and/or Federal inspectors permission to enter the dwelling after reasonable notice to perform inspections
to verify the existence and quality of work performed by the Contractor/Agency and compliance with local, State, and/or Federal building codes and
programmatic guidelines and acknowledge that a permit may be required for specific weatherization work. I understand that I may be held
financially responsible for the weatherization work if I refuse to allow access for inspection and permitting purposes.
7. I shall not remove any permanently installed energy conservation measures unless they are damaged or no longer functional in the residence from
where they were installed.
Additional Certifications For Owner-Occupants ONLY:
8. I acknowledge and agree that this property is not for sale at the time of qualifying for the program and will not be offered for sale or otherwise
distributed for at least sixty days following the completion of weatherization services.
9. Mobile home units only: I acknowledge that I may not receive services that require a permit if the registration on the mobile unit is not up-to-date.
Additional Certifications For Tenants ONLY:
10. I acknowledge that the Rental Property Owner must grant the Contractor/Agency the same permissions by signing CSD 515B Energy Service
Agreement for Rental Property Owner before any services are rendered.
1
STATE OF CALIFORINA
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 515A (Rev. 2/12/16)
ENERGY SERVICE AGREEMENT FOR OCCUPANT
11. I understand that the Property Owner cannot raise the rent of the unit for a period of two years from the date of weatherization because of the
increased value of the unit due solely to weatherization measures provided by the Contractor/Agency (allowable factors for rent increase include an
actual increase in property taxes, actual cost of amortizing other improvements to the property accomplished after the date of work completed by
the Contractor/Agency, or actual increases in expenses of maintaining and operating this property).
12. I acknowledge that I have been provided a copy of this Agreement explaining its terms effective for a two year period after weatherization services
have been completed. Complaint Process: In the event the provisions of this Agreement related to increased rent or the landlord’s failure to
decrease utility costs for master metered units are not met, tenants may contact the Contractor/Agency to submit a verbal or written complaint,
which will be investigated by the Department of Community Services and Development. Contractor/Agency contact information is located on this
Agreement under the section entitled, “Contractor/Agency Assurance.”
13. I may retain the replacement energy conservation measure installed by the CSD weatherization program(s) if the replaced appliance was my
personal property .
I CERTIFY THAT I am the Owner-Occupant or Tenant residing in the dwelling listed above that serves as my primary residence and that all given
statements are true and correct to the best of my knowledge. I have read and understand these TERMS and RELEASE, and agree to be bound by all
of its terms and conditions in order to receive weatherization services under the CSD weatherization program(s).
Owner-Occupant or Tenant’s Signature
Date
Contractor/Agency Assurance
Contractor/Agency (Print name)
SAN JOAQUIN COUNTY, DEPT OF AGING AND COMMUNITY
SERVICES, WEATHERIZATION PROGRAM
CSLB Number (if applicable)
City
STOCKTON
Address
DEPT OF
AGING AND
ZIP Code
95297-0106
Contractor/Agency Email Address
Contractor/Agency Telephone Number
209-468-0439
Contractor/Agency FAX Number
209-932-2673
[email protected]
The Contractor/Agency agrees to the following:
1. Shall be responsible for the feasible cost of weatherization measures performed other than cash contribution from the Owner or Owner Agent, if
applicable, and any subsequent non-compliance.
2. Shall ensure that the Contractor/Agency is properly insured.
3. Shall ensure that work is conducted in a professional manner and meets program and building code standards.
4. Shall not make any significant structural changes to the dwelling without requesting written permission specifically describing the change from the
dwelling owner.
5. Shall provide in writing a list of all weatherization measures installed in the unit.
6. Shall assure that the owner, or owner's agent, and tenant data shall be maintained in a confidential manner to assure compliance with the Information
Practices Act of 1977, as amended, and the Federal Privacy Act of 1974, as amended.
Agency Program Manager’s Signature
Agency Program Manager's Name (Print name)
2
Date
WEATHERIZATION FORM
STATE OF CALIFORINA
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 515B (Rev. 2/12/16)
ENERGY SERVICE AGREEMENT FOR RENTAL PROPERTY OWNER
Single-Family/Mobile Home Dwelling Information
Tenant Name
Dwelling Address
City
Zip Code
Type
Single
Mobile
Multi-Family Dwelling/Complex Information
Number of Eligible Buildings in Complex:
Use additional pages, if necessary.
Building #1
Complex/Building Name (if applicable)
City
Building Address
ZIP Code
List Qualified Units
# of Units in Building
# of Units to be Weatherized
# of Vacant & Unqualified Units
List Vacant and Unqualified Units
Building #2
Complex/Building Name (if applicable)
City
Building Address
ZIP Code
List Qualified Units
# of Units in Building
# of Units to be Weatherized
# of Vacant & Unqualified Units
List Vacant and Unqualified Units
Building #3
Complex/Building Name (if applicable)
City
Building Address
ZIP Code
List Qualified Units
# of Units in Building
# of Units to be Weatherized
# of Vacant & Unqualified Units
List Vacant and Unqualified Units
Owner and Owner's Agent Information
Owner (Print or type name)
Apt./Unit No.
Address
City
ZIP Code
Owner Email Address
Owner Telephone Number
Owner FAX Number
If the Owner uses an agent for the above-referenced property, complete both Owner and Agent information.
Agent (Print or type name)
Apt./Unit No.
Address
City
ZIP Code
Agent Email Address
Agent Telephone Number
Agent FAX Number
Page 1 of 3
STATE OF CALIFORINA
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 515B (Rev. 2/12/16)
ENERGY SERVICE AGREEMENT FOR RENTAL PROPERTY OWNER
Owner or Owner's Agent Acceptance of Terms for CSD Weatherization Services
(to be completed by the Owner or Owner's Agent)
I agree to accept all of the following TERMS required for my rental property to receive services from the Department of Community Services and
Development (CSD) weatherization program(s):
1. I certify that I am the Owner (or Owner's Agent) of the above-listed rental property.
2. I grant the Contractor/Agency permission to enter my property to perform assessments, conduct diagnostics, take photos only of weatherization work
to be performed or deferred (as it relates to individual or whole house services), install feasible weatherization measures and perform inspections in
accordance with CSD weatherization program policies and standards to the above-listed rental property.
3. I acknowledge that an assessment of my property is necessary to determine the work that can be performed and that the work that is available may
be limited due to the needs and condition of my property. Identified work may not be provided if it does not meet all program requirements and
specifications and may lead to full or partial deferral of work. My refusal of certain work may prevent the installation of other identified work in
accordance to program requirements.
4. I shall not remove any energy conservation measures unless they are damaged or no longer functional in the rental property from where they were
installed. If the replaced item (i.e. refrigerator or other appliance) was the personal property of my tenant, the tenant shall retain the replacement
energy conservation measure installed by the CSD weatherization program(s).
5. Mobile home units only: I acknowledge that my property may not receive services that require a permit if the registration is not up-to-date.
6. I hereby release and pledge to hold harmless the Contractor/Agency listed below, and its staff, from any liability in connection with any work identified
on a summarized list except as a consequence of gross negligence or willful and wanton misconduct.
7. I authorize the Contractor/Agency to access my complex's utility company master-metered records to obtain only energy usage data for a period of
one year before and two years after weatherization measures are installed.
8. I grant the Contractor/Agency, local, State and/or Federal inspectors permission to enter the dwelling after reasonable notice to perform inspections to
verify the existence and quality of work performed by the Contractor/Agency and compliance with local, State, and/or Federal building codes and
programmatic guidelines and acknowledge that a permit may be required for specific weatherization work. I understand that I may be held financially
responsible for the weatherization work if I refuse to allow access for inspection and permitting purposes.
9. I certify that I, as the Owner or Owner's Agent, shall ensure that gas or electric service, or both, that is provided by a master-meter to tenants shall be
charged at the utilities' costs in accordance with California Public Utilities Commission Code Section 739.5 or other applicable government
regulations.
10. I certify that I, as the Owner or Owner's Agent, shall not raise the rent of any weatherized unit for a period of two years from the date of weatherization
because of the increased value of the unit due solely to weatherization measures provided (allowable factors for rent increase include an actual
increase in property taxes, actual cost of amortizing other improvements to the property accomplished after the date of work completed by the
Contractor/Agency, or actual increases in expenses of maintaining and operating this property).
11. I acknowledge and agree that this property is not for sale at the time of qualifying for the program and will not be offered for sale or otherwise
distributed for at least sixty days following the completion of weatherization services.
12. I certify that I shall provide a copy of this Agreement explaining its terms to all tenants and subsequent tenants residing in the unit within the two year
period. Complaint Process: In the event the provisions of this Agreement related to increased rent or the landlord’s failure to decrease utility costs for
master metered units are not met, tenants may contact the Contractor/Agency to submit a verbal or written complaint, which will be investigated.
Contractor/Agency contact information is located on this Agreement under the section entitled, “Contractor/Agency Assurance.”
Additional Certification for Unoccupied Multi-Unit Dwellings ONLY:
13. I agree that "rent" is defined as the tenant's monthly payment to the Owner (non-subsidized housing) or the contract rent (subsidized housing).
14. I shall submit to the Contractor/Agency a schedule of rents prior to commencement of work.
15. Federal, State or Local Government Rehabilitation Projects only: I certify that if a vacant unit is counted as being an eligible household for purposes
of meeting the minimum threshold for whole building weatherization (66% rule), then the unit will become occupied by an eligible family within 180
days after the completion of weatherization (CFR 440.22(b)(2)(ii)).
Page 2 of 3
STATE OF CALIFORINA
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 515B (Rev. 2/12/16)
ENERGY SERVICE AGREEMENT FOR RENTAL PROPERTY OWNER
I CERTIFY THAT I am the Owner or Owner's Agent of the Dwelling or Complex listed above, and that all given statements are true and correct to the best
of my knowledge. I have read and understand these TERMS and RELEASE, and agree to be bound by all of its terms and conditions in order for my
property to receive weatherization services under the CSD weatherization program(s).
Owner’s (or Owner's Agent’s) Signature
Date
Contractor/Agency Assurance
Contractor/Agency (Print or type name)
SAN JOAQUIN COUNTY, DEPT OF AGING AND COMMUNITY
SERVICES, WEATHERIZATION PROGRAM
CSLB Number (if applicable)
City
Address
DEPT OF AGING AND COMMUNITY SVCS, PO BOX 201056
ZIP Code
STOCKTON
Contractor/Agency Telephone Number
95297-0106
209-468-0439
Contractor/Agency Email Address
Contractor/Agency FAX Number
[email protected]
209-932-2673
The Contractor/Agency agrees to the following:
1. Shall be responsible for the feasible cost of weatherization measures performed other than cash contribution from the Owner or Owner Agent, if
applicable, and any subsequent non-compliance.
2. Shall ensure that the Contractor/Agency is properly insured.
3. Shall ensure that work is conducted in a professional manner and meets program and building code standards.
4. Shall not make any significant structural changes to the dwelling without requesting written permission specifically describing the change from the
dwelling owner.
5. Shall provide in writing a list of all weatherization measures installed in the rental unit.
6. Shall assure that the owner, or owner's agent, and tenant data shall be maintained in a confidential manner to assure compliance with the Information
Practices Act of 1977, as amended, and the Federal Privacy Act of 1974, as amended.
Contractor/Agency Program Manager’s Signature
Contractor/Agency Program Manager's Name (Print name)
Date
Required Documentation:
Rent schedule received from Property Owner, if applicable?
Y
N
Page 3 of 3
If applicable, CSD 75
completed?
Y
N
MICHAEL MILLER, Director
CHRIS WOODS, Assistant Director
CalWORKs
CalFresh
Medi-Cal
Children’s Services
Mary Graham Children’s Shelter
First 5 San Joaquin
Aging and Community Services
SAN JOAQUIN COUNTY
P.O. Box 201056
102 South San Joaquin Street
Stockton, CA 95201-3006
Aging and Community Services
Tel (209) 468-2202
Fax (209) 468-2207
YOUR RIGHTS UNDER THE LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP)
You have the right to appeal if...
your application was denied.
your application was not responded to in a timely manner.
you disagree with the outcome of your application.
you are not satisfied with the work performed on your home.
You may appeal within five (5) working days of receipt of the denial letter by contacting the San Joaquin County Aging &
Community Services Energy Program Coordinator:
San Joaquin County Human Services Agency
Aging & Community Services
Attn: Energy Program Coordinator
P O Box 201056
Stockton, CA 95201
Upon receipt of your appeal, the Energy Program Coordinator will review your case and make a good-faith effort to
resolve your appeal. If your appeal is not resolved to your satisfaction by the Energy Program Coordinator, you may then
appeal, in writing, to the San Joaquin County Aging & Community Services Community Services Program Manager:
San Joaquin County Human Services Agency
Aging & Community Services
Attn: Kristi Rhea
P O Box 201056
Stockton, CA 95201
Upon receipt of your appeal, the Community Services Program Manager will respond to you in writing, within ten (10)
business days, of whether or not the decision remains in effect. If your appeal is not resolved to your satisfaction by the
Community Services Program Manager, you may then appeal to the California Department of Community Services and
Development (CSD):
CSD Call Center / Toll Free: (866) 675-6623
California Department of Community Services and Development
2389 Gateway Oaks, Suite 100
Sacramento, CA 95833
Our Mission is to lead in the
creation and delivery of services that improve
the quality of life for our community.
what
we
do
The Office of Inspector General (OIG)
fights waste, fraud, and abuse in Medicare,
Medicaid, and more than 300 programs of the
Department of Health and Human Services.
The result? Taxpayer and patients save money;
quality of health care is protected.
Billions levied in fines,
penalties, and settlements
Thousands of criminals
excluded as providers from
Federal health programs
Hundreds of enforcement
actions annually
The Hotline processes tens of thousands of tips
each year from HHS employees, seniors, health
care providers, and others. Those tips, along
with other OIG initiatives, result in:
$
1-800-HHS-TIPS
OIG.HHS.GOV/REPORT-FRAUD
SCAN HERE
TO REPORT FRAUD
PHONE : 1-800-HHS-TIPS
FAX : 1-800-223-8164
TTY : 1-800-377-4950
MAIL
U.S. Department of Health and Human Services
Office of Inspector General
ATTN: OIG HOTLINE OPERATORS
PO Box 23489
Washington, DC 20026
oig.hhs.gov
OIG Hotline
report
fraud
Report fraud, waste, and abuse
in HHS programs.
U.S. Department of
Health and Human Services
Office of Inspector General
1-800-HHS-TIPS
MEDICARE & MEDICAID FRAUD
fraud
Grant or contract fraud occurs when Federal
funds are misused by those who receive them or
when taxpayer dollars are awarded under false
Grant or Contract Fraud
fraud
employee crimes & misconduct
fraud
pretenses.
HHS employees are expected to adhere to
certain standards of conduct, which,
if violated, could reflect poorly on the U.S.
Department of Health and Human Services and
on the Federal Government.
Medicare and Medicaid provide health
insurance to 1 in 3 Americans: the elderly, those
with low incomes, and people with certain
disabilities. The programs’ sheer size makes
them a criminal target.
AA Billing for services, prescriptions, supplies, or
equipment that were not needed or provided
AA Using Federal funds to purchase items that are
not for Government use
AA Falsifying information in grant applications or
contract proposals
AA Misusing Government property because of
deficient practices, systems, or controls
AA Mismanaging or wasting Federal funds
extravagantly, carelessly, or needlessly
AA Stealing or embezzling Government
property or money
Types of Employee
Crimes & Misconduct
AA Submitting duplicate claims for the
same service
AA Billing more than one grant or contract for the
same work
AA Soliciting or accepting gifts from outside
sources
Types of Grant
or Contract Fraud
AA Charging for a more expensive or complex
service than what was actually provided
AA Billing for expenses not incurred as part of the
grant or contract
Types of Health Care
Fraud and Abuse
AA Billing a service as covered by Medicare or
Medicaid—when it actually isn't
AA Billing for work that was never performed
AA Falsifying test results or other data
AA Abusing authority
AA Involving yourself in alleged or
suspected situations
AA Violating conflict of interest standards
AA Influencing the award of a grant or contract
to benefit a particular company, friend, or
family member
AA Committing official or moral misconduct, on
or off duty
AA Failing to meet quality of care standards,
resulting in patient abuse and neglect
AA Misrepresenting the service provided
AA Substituting approved materials with
unauthorized products
oig.hhs.gov/report-fraud
AA Misusing Government time, equipment,
or information
Save Money and Energy Today
A
n energy-efficient home will keep
your family comfortable while
saving you money. Whether you take
simple steps or make larger investments
to make your home more efficient, you’ll
see lower energy bills. Over time, those
savings will typically pay for the cost
of improvements and put money back
in your pocket. Your home may also be
more attractive to buyers when you sell.
The 115 million residences in America
today collectively use an estimated 22.5%
of the country’s energy. Unfortunately,
a lot of energy is wasted through leaky
windows or ducts, old appliances, or
inefficient heating and cooling systems.
When we waste energy in our homes, we
are throwing away money that could be
used for other things. The typical U.S.
family spends at least $2,200 a year on
home utility bills. You can lower this
amount by up to 25% through following
the Long Term Savings Tips in this guide.
The key to these savings is to take a
whole-house approach—by viewing
your home as an energy system with
interdependent parts. For example, your
heating system is not just a furnace—it’s
a heat-delivery system that starts at the
furnace and delivers heat throughout your
home using a network of ducts. Even a
top-of-the-line, energy-efficient furnace
will waste a lot of fuel if the ducts, walls,
attic, windows, and doors are leaky or
poorly insulated. Taking a whole-house
approach to saving energy ensures that
dollars you invest to save energy are
spent wisely.
Tips to Save Energy Today
Easy low-cost and no-cost
ways to save energy
■■
Install a programmable thermostat
to lower utility bills and manage your
heating and cooling systems efficiently.
■■
Air dry dishes instead of using your
dishwasher’s drying cycle.
■■
Turn things off when you are not in the
room such as lights, TVs, entertainment
systems, and your computer and monitor.
■■
Plug home electronics, such as TVs and
DVD players, into power strips; turn the
power strips off when the equipment
is not in use—TVs and DVDs in standby
mode still use several watts of power.
■■
Lower the thermostat on your water
heater to 120°F.
■■
Take short showers instead of baths and
use low-flow showerheads for additional
energy savings.
■■
Wash only full loads of dishes and clothes.
■■
Air dry clothes.
■■
Check to see that windows and doors
are closed when heating or cooling
your home.
■■
Drive sensibly; aggressive driving such
as speeding, and rapid acceleration and
braking, wastes fuel.
■■
Look for the ENERGY STAR® label on light
bulbs, home appliances, electronics, and
other products. ENERGY STAR products
meet strict efficiency guidelines set by the
U.S. Environmental Protection Agency and
the U.S. Department of Energy.
■■
Visit energysaver.gov for more
energy-saving ideas.
3
Your Home’s Energy Use
A
home energy assessment
(sometimes referred to as an
energy audit) will show what parts of
your house use the most energy and
suggest the best ways to cut energy
costs. You can conduct a simple home
energy assessment by doing it yourself
(DIY) or, for a more detailed assessment,
contact your local utility or an energy
auditor. Also, you can learn more about
home energy audits and find free tools
and calculators on energysaver.gov,
the Residential Services Network at
resnet.us, or the Building Performance
Institute at bpi.org.
DIY Energy Assessment Tips
• Check the insulation in your attic,
exterior and basement walls,
ceilings, floors, and crawl spaces.
To determine the insulation R-values
in different parts of your home,
visit the Weatherization section of
energysaver.gov.
• Check for air leaks around your
walls, ceilings, windows, doors,
lighting and plumbing fixtures,
switches, and electrical outlets.
• Check for open fireplace dampers.
• Make sure your appliances and
heating and cooling systems are
properly maintained. Check your
owner’s manuals for the recommended maintenance.
• Study your family’s lighting needs
and look for ways to use controls—
like sensors, dimmers, or timers—
to reduce lighting use.
How We Use Energy
in Our Homes
Refrigeration
5%
Space
Heating
42%
Lighting
5%
Cooling
6%
Other
24%
Heating accounts for
the biggest portion of
your utility bills. Source:
U.S. Energy Information
Administration, AEO2014 Early
Release Overview.
Water
Heating
18%
To download the PDF guide: Energy Saver - Tips on Saving Money & Energy at
Home, visit sjchsa.org and click on Forms, or visit energysaver.gov.
4
To complete and print the electronic version, visit sjchsa.org and click on Forms, or visit consumer.gov.
Make a Budget
Use this worksheet to see how much money you spend this month. Then, use this month’s
information to help you plan next month’s budget.
Some bills are monthly and some come less often. If you have an expense that does not occur
every month, put it in the “Other expenses this month” category.
MONTH YEAR
My income this month
Income
Paychecks (salary after taxes, benefits, and check cashing fees)
Other income (after taxes) for example: child support
Total monthly income
Monthly total
$
$
$
0.00
Income
Monthly total
$
$
$
$
$
FOOD
Groceries and household supplies
Meals out
Other food expenses
$
$
$
Public transportation and taxis
Gas for car
Parking and tolls
Car maintenance (like oil changes)
Car insurance
Car loan
Other transportation expenses
$
$
$
$
$
$
$
HOUSING
Expenses
Rent or mortgage
Renter's insurance or homeowner's insurance
Utilities (like electricity and gas)
Internet, cable, and phones
Other housing expenses (like property taxes)
TRANSPORTATION
My expenses this month
HEALTH
Expenses
Medicine
Health insurance
Other health expenses (like doctors' appointments and eyeglasses)
Monthly total
$
$
$
PERSONAL AND FAMILY
Child care
Child support
Money given or sent to family
Clothing and shoes
Laundry
Donations
Entertainment (like movies and amusement parks)
Other personal or family expenses (like beauty care)
$
$
$
$
$
$
$
$
FINANCE
Fees for cashier's checks and money transfers
Prepaid cards and phone cards
Bank or credit card fees
Other fees
$
$
$
$
OTHER
Make a Budget
School costs (like supplies, tuition, student loans)
Other payments (like credit cards and savings)
Other expenses this month
$
$
$
Total monthly expenses
$
$
0.00
Income
$
0.00
Expenses
$
0.00
Expenses
0.00
Maybe your income is more than your expenses. You have money left to save or spend.
Maybe your expenses are more than your income. Look at your budget to find expenses to cut.
Print Form
September 2012 | Federal Trade Commission | consumer.gov
*
*
ENERGY ASSISTANCE
*
*
*
SJC LIHEAP ASSURANCE 16 RESOURCE AND REFERRAL
*
Pacific Gas and Electric Company- 1-800-743-5000
California Alternate Rates for Energy (CARE), Family Electric Rate Assistance (FERA)
Medical Baseline Allowance (Life Support), Energy Partners (Free Home Improvements)
Lodi Electric Utility | 209-333-6762
Single Household Alternative Rate for Energy (SHARE) Residential Medical Discount
Program
Modesto Irrigation District (MID) | 209-526-7373
Community Alternative Rates for Electric Service (CARES) Residential Life Support
Services.
Salvation Army REACH
REACH is a one-time energy-assistance program sponsored by PG&E and administered
through the Salvation Army from 170 offices in northern and central California.
Stockton | 209-948-8955
Lodi | 209-369-5896
Tracy | 209-836-2346
California Public Utilities Commission (CPUC) | 1-800-649-7570
*
*
COMMUNITY CONNECTIONS
*
*
*
If your energy, telephone, or water has been shut off because you fell behind on your bills,
the CPUC may be able to help you get your services restarted.
*
INFORMATION AND ASSISTANCE
San Joaquin County Aging and Community Services
Information and Assistance Program
209-468-1104 | 1-800-510-2020
Community Action Centers (CAC’s)
Boggs Tract Center 533 S. Los Angeles Avenue Stockton, CA 95203 (209) 468‐3978 Northeast Center 2885 E. Harding Way Stockton, CA 95205 (209) 468‐3918 Garden Acres Center 607 Bird Avenue Stockton, CA 95215 (209) 468‐3984 Ta Center 389 W. Downing Avenue Stockton, CA 95206 (209) 468‐4168 Kennedy Center 2800 S. ‘D ‘Street Stockton, CA 95206 (209) 468‐3986 Thornton Center 26675 N. Sacramento Blvd Thornton, CA 95686 (209) 794‐2144 Larch Clover Center 11157 W. Larch Road Tracy, CA 95376 (209) 831‐5920 For over twenty-five years, the San Joaquin Community Centers have been providing a wide variety of direct and referral services to individuals and families through
a network of eight (8) community centers. Center staff provides linkage and referrals to agencies to assist individuals and families in the areas of human services,
employment, health, nutrition, housing assistance and education services.
Lodi Center 415 S. Sacramento Street Lodi, CA 95240 (209) 331‐7516 ASKED QUESTIONS
SAN JOAQUIN COUNTY HOME ENERGY ASSISTANCE PROGRAM
209.468.3988 1.877.977.3988 | 209.932.2649 fax | www.sjchsa.org
FREQUENTLY
Q: Must the utility bill be in my name to apply for help?
A: No, however the applicant must reside at the service address and be
responsible for energy costs in the home.
Q: How long will it take to process my application?
A: Please allow 4 to 6 weeks for processing. There is no need to call the
office. If your application is approved, a benefit payment will be issued
directly to your utility company in one to two billing cycles after approval.
Q: How much do I qualify for?
A: The benefit amount is based on several factors: the number of people
living in the household, the total household income, and energy account
status. Non-emergency benefits range from $190 to $330.
Q: I have a 48 hour notice, or my utility account is shut-off. What
should I do?
A: Call the office Monday through Friday between the hours of 9:00AM
and 12:00PM and 1:00PM and 4:00PM for crisis instructions. The Energy
Crisis Intervention Program offers immediate payment assistance to
households experiencing an energy crisis.
IMPORTANT: Phone lines are extremely busy. If you are unable to make
contact with the office, continue to pay your utility bill, or make payment
arrangements to avoid service disconnection, or to restore services.
DOCUMENT CHECKLIST
All documentation must be submitted before your application can be reviewed. Check off the
documents attached to your application below.
Please send copies. Original documents will not be returned.
ALL DOCUMENTS MUST BE CURRENT WITHIN 30 DAYS OF APPLICATION DATE
Energy Bill:




Pacific Gas & Electric, Lodi Electric Utility, Modesto Irrigation District Bills; Sub-metered, Propane Statements.
Applicants MUST submit ALL pages of the regular bill.
FOR DELINQUENT/OR SHUT-OFFACCOUNTS: PG&E Account Information Sheet for Pacific Gas & Electric; pink
or yellow notice AND regular bill for Lodi Electric Utility; Delinquent and regular bill for Modesto Irrigation.
Additional Heat Source: Applicants MUST also include bills, invoices or receipts for gas, propane, wood, or kerosene if applicable.
Current Gross Earnings for the last thirty (30) days for all household members:















Cal Works, Cal Fresh, General Assistance: Passport to Service, Notice of Action, or voucher.
Supplemental Security Income (SSI): Notice of Planned Action or Form 2458; annual award letter, printout
from Social Security Office; copy of bank statement showing SSI direct deposit; copy of SSI check.
Social Security (SSA): copy of current check(s); SSA Form 4926, or 2458; printout from Social Security
Administration Office; Bank Statement showing direct deposit.
Pension and Annuities: copy of a current check; verification on letterhead dated within 6 weeks of intake date,
or annual statement from pension plan dated for the current year.
Wages: copy of current paycheck stub(s) covering a one-month period and showing gross income.
Interest Income: monthly or quarterly bank statement; statement of interest income from bank or agency.
Disability Compensation: copy of a current check; printout or letter from agency or insurance company
verifying the compensation amount.
Unemployment Benefits: copy of current check(s) or stubs; printout from Employment Development
Department.
Child and/or Spousal Support: copy of current benefit statement or check.
Support from an Individual: copy of check or statement signed by person providing the support.
General Assistance: Notice of Action from County Social Services; copy of a current check.
Veteran’s Benefits: letter indicating receipt of Veteran’s Pension; copy of Veteran’s Administration check.
Self Employed ONLY: current signed Federal Tax Form 1040 and Schedule C (2015 Federal Tax Form 1040
valid through April 15, 2017); signed and dated copy of ledger, journal, or profit and loss statement.
ALL ADULTS IN THE HOUSEHOLD, 18 YEARS OR OLDER, WITH ZERO INCOME: will need to complete
Form CSD 43B - Certification of Income and Expenses. Contact the office, pick up forms in the lobby, or print
online under the FORMS icon @ www.sjchsa.org.
HOUSEHOLDS WITH ZERO TOTAL INCOME: Applicant must fill out and submit form Statement of Financial
Support. Applicants claiming no income must reveal their source(s) of support. Applicant households with zero
income or expenses that exceed the income, requires the Program to determine how the household met living
expenses for the last 30 days. Current living expenses include but are not limited to: rent/mortgage, utilities
(gas, power, trash, and phone), food, insurance and car payments. Inadequate information on the form is
cause for denial of benefits. Contact the office, pick up forms in the lobby, or print forms from the website
under the FORMS icon @ www.sjchsa.org.
Proof of US Citizenship or Legal Residency:




US Birth Certificate
Current United States Passport
Form N-561 Certificate of Citizenship
Valid Form I-551 Alien Registration Card
THIS IS A PARTIAL LISTING OF ACCEPTABLE DOCUMENTS. CONTACT THE OFFICE FOR ADDITIONAL INFORMATION.
PO BOX 201056 | STOCKTON, CA 95201
209-468-3988 | Toll Free 1-877-977-3988 | www.sjchsa.org