LIHEAP Application - English - Merced County Community Action Agency

LIHEAP Application - English

YOU MUST SUBMIT THE FOLLOWING DOCUMENTS:
- CURRENT PHOTO ID (REAL ID): UNITED STATES ID or DRIVER’S LICENSE FOR ALL THE ADULTS LIVING IN THE HOUSEHOLD (18 YEARS OF AGE AND OLDER). IF ID’S STATE FEDERAL LIMITS APPLY PLEASE ALSO MAIL US COPY OF BIRTH CERTIFICATE, U.S. PASSPORT, OR DOCUMENT OF DIRECT RECEIPT OF SSI OR SSA BENEFITS.
- ALL PAGES OF CURRENT ENERGY BILLS: (PG&E, TID, MID, PROPANE, WOOD, ETC.) MUST SHOW ACCOUNT NUMBER, NAME, PHYSICAL ADDRESS, MAILING ADDRESS, BILLING DATE & DUE DATE, TOTAL CURRENT CHARGES & ANY PREVIOUS BALANCE. LATE NOTICES (48 HOUR NOTICES) WILL NOT BE ACCEPTED. PLEASE BRING IN OR MAIL ALL YOUR ENERGY BILLS.
- SOCIAL SECURITY CARDS: FOR EVERYONE LIVING IN THE HOUSEHOLD. (MEDI-CAL CARDS, SHOT RECORDS AND BIRTH CERTIFICATE WILL BE ACCEPTED FOR CHILDREN ONLY).
- VERIFICATION OF CALFRESH/CALWORKS BENEFITS for CURRENT MONTH: Declaration statement will be necessary attesting to additional income at your appointment, from everyone in Household who has obtained income within the last 4 weeks such as Wages, Social Security, Child Support, Unemployment, Disability, Alimony, Pension, and or any Cash Gifts or Borrowed Money.
  **If Verification of Benefits is NOT provided, ALL income within last 4 weeks for must be provided**
- If your income is from employment please provide current copy of pay stub(s) covering 1 month of gross income before deductions (if multiple stubs, they must be consecutive).
- If your income is from social security please send a copy of your current years benefit letter, or copy of your most current bank statement showing direct deposit or a copy of the most recent check.
- If your income is from Pension/Retirement please provide copy of check stub or an award letter current within the last 6 weeks.
- If your income is from Unemployment benefits please provide current check stubs (must be consecutive), or current printout, or current award letter.
- If your income is from Workers compensation please provide copy of current check(s), current check stubs(s), current award letter.
- If your income is from Self-employment and/or Rental Income please provide current years tax form 1040 and 1040 schedule 1. Form 1040, Schedule 1 must show dollar amount, either on line 12 or 17, to be valid income verification for self-employment or rental income. Schedule C (for self-employment) or Schedule E (for rental income) must be submitted with the current 1040.
- If your income is from Public assistance (TANF) please provide current Notice of Action or Passport to Services or copy of bank statement showing direct deposit.
- If your income is from Child support please provide copy of most current bank statement or most current monthly statement. If child support is a mutual agreement between the parents please provide a letter written by the parent paying the child support stating how much was paid in the last 4 weeks. The letter must state the name of the person paying the child support and their signature, the date the letter was written, and their phone number.
- If your household did not have any income in the last 4 weeks please fill out the form CSD 43B.

If you have any questions or concerns, please do not hesitate to call us at (209) 723-3201

State of California Department of Community Services and Development

Energy Intake Form | CSD 43 (07/2024)

Name*

First Middle Last

Date of Birth*

Service Address - Address where you live (this cannot be a P.O. Box)*

Service Address Unit Number Service City Service State Service Zip

How long have you lived at this address?*

Is your service address the same as mailing address?*

Do you own or rent your home?*

Own
Rent

Mailing Address*

Mailing Address Unit Number Mailing City Mailing State Mailing Zip Code

Social Security Number (SSN)*

Telephone Number*

Email Address:*

People Living In Household*

Enter the total number of people living in the household, including yourself

Income*

Enter the total number of people who receive income

Department of Community Services and Development CSD 43B (rev.12/2013)

CERTIFICATION OF INCOME AND EXPENSES

You are being asked to complete this form because you requested assistance, and state that your entire household cannot provide proof of income. The State of California requires the applicant to report all sources of income. This form will help us understand how you are meeting expenses. Please complete the information below:

Name

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Section 1: Do you have sources of income you forgot to report?

During the previous month have you been employed part time?*

During the previous month have you been self-employed?*

During the previous month did you receive money for any work that you perform only once in a while, like yard work, child care, donating blood, etc?*

During the previous month have you received any gifts of money from anyone? If yes, please list the name and phone number of the person who gave you the gift:*

During the previous month did you receive any of the following: (select any that apply)

WORKER’S COMP
UNEMPLOYMENT
GOVERNMENT SPONSORED BENEFITS
CHILD SUPPORT

Do you receive any of the following: (select any that apply)

Section 2: Are you spending your savings or borrowing money to cover monthly expenses?

Are you using savings or a home equity loan?*

How much?*

Are you using some other asset?*

How much?*

Are you borrowing from credit cards?*

How much?*

Are you borrowing from some other source?*

How much?*

Section 3: Please tell us how you paid these monthly expenses during the previous months:

Rent or Mortgage

MONTHLY COST*

HOW HAS THE EXPENSE BEEN PAID?

IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:

Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Utility Bills

MONTHLY COST*

HOW HAS THE EXPENSE BEEN PAID?

IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:

Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Food

MONTHLY COST*

HOW HAS THE EXPENSE BEEN PAID?

IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:

Name

First Last

Phone

Address

Street Address Address Line 2 City State ZIP Code

Section 4: If none of the above applies to you, please explain how your monthly expenses were paid:

By signing this form, I affirm that I believe these facts are accurate and true. I give the Service Provider my permission to verify this information.

I may be held liable under federal or state law for knowingly making false or fraudulent statements

Signature:*

First Last

Date

Demographics Enter the total number of people living in the household who are:

Ages 0-2 years

Ages 3-5 years

Ages 6-18 years

Ages 19-59 years

Ages 60 and older

Disabled

Native American

Seasonal or Migrant Farmworker

Enter the total gross monthly income for all people living in the household:

TANF / CalWorks

SSI / SSP

SSA / SSDI

Paycheck(s)

Interest

Pension

Other

Total Monthly Income

HOUSEHOLD MEMBERS*

SELECT THE NUMBER HOUSEHOLD MEMBERS, THEN FILL OUT THE INFORMATION FOR ALL HOUSEHOLD MEMBERS.

Applicant (Household Member 1)

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 2

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 3

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 4

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 5

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 6

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 7

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 8

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 9

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 10

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 11

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 12

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 13

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 14

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 15

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 16

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 17

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Member 18

Name*

First Last

Relation to Applicant*

Date of Birth*

Amount of Gross Monthly Income*

(Before Taxes and Deductions)

Source of Income*

Household Total Monthly Gross Income

Are you or someone in your houshold CURRENTLY receiving CalFresh (Food Stamps)?*

PAY BILL*

To which energy bill (CHOOSE ONLY ONE) do you want the LIHEAP benefit to be applied? (Attach complete copy of most recent bill or receipt)

Enter the energy company and account number:

Company Name:*

Account #:*

Is your utility service shut-off?*

Do you have a past due notice?*

Are your utilities included in rent or submetered*

Are your utilities all electric?*

Is your Natural Gas Company the same as your Electric Company?*

WOOD, PROPANE or FUEL OIL SERVICE (WPO)

Are you currently out of fuel?*

(Wood, Propane, Oil, Kerosene, Other Fuels)

List the approximate number of days until you run out of fuel*

(Wood, Propane, Oil, Kerosene, Other Fuels)

ENERGY INFORMATION

The questions below are MANDATORY. Please check all energy sources used to heat your home. A copy of ALL recent energy bills and/or receipts for any home energy cost must be provided. NOTE: A copy of an electric bill must be included even if you do not use electricity to heat your home.

What is the main fuel used to HEAT your home?*

One main heating source MUST be checked.

Are you the account holder:

Electric Bill*

Natural Gas Bill*

The information on this application will be used to determine and verify my eligibility for assistance. By signing below, I give my consent (permission) to CSD, its contractors, consultants, other federal or state agencies (CSD Partners) and to my utility company and its contractors, to share information about my household's utility account, energy usage and/or other information needed to provide services and benefits to me as described at the end of the form. My consent shall be effective for the period beginning 24 months prior to, and continuing for 36 months after, the date signed below. 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.

APPLICANTS SIGNATURE*

First Last

Typing your name here will count as your signature.

Date*

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.

LIHEAP Energy Conservation Education

Participant:*

First Name Middle Initial Last Name

Address

Street Address Address Line 2 City State ZIP Code

Telephone No.

To assist in reducing energy consumption and energy costs, the Community Action Agency has provided Energy Conservation Education and Informational Literature to me on the following topics:

Weatherization Referral*

Cooling/Summer Tips*

Heating/Winter Tips*

Water Heaters*

Cooking*

Appliances*

Lighting*

Miscellaneous*

Signature of Participant*

First Last

Date

This field is hidden when viewing the form

Signature of Intake Worker

First Last

This field is hidden when viewing the form

Date

Merced County Community Action Agency Energy/Weatherization Department 1235 W. Main St. – P.O. Box 2085 – Merced, CA

LIHEAP APPLICANT FINANCIAL MANAGEMENT COUNSELING

Participant:*

First Name Middle Initial Last Name

Address*

Street Address Address Line 2 City State ZIP Code

Phone #*

Name of Program in which assistance is being requested:*

1. Monthly Household Income:

a. Source of Income:*

b. Gross Monthly Income:*

c. Net Monthly Income:*

2. Monthly financial obligations - (monthly bills paid by applicant)

a. Rent/Mortgage payment:*

b. Food/Household Exp:*

c. Credit Card payment:*

d. TV/Cable payment:*

e. Telephone payment:*

f. Water/Garbage payment:*

g. Utility payment:*

(PG & E, MID, TID, Propane, etc.)

h. Transportation Exp.:*

i. Car payment:*

j. Other monthly payments (be Specific)

Name

Amount

Name

Amount

Name

Amount

GRAND TOTAL:*

Participants in CAA’s direct assistance programs are required to present documented proof of monthly income.

3. Possible available cash after all monthly obligations are paid:*

4. Problems – (why does applicant need financial assistance from CAA?)*

Utility Company Name:*

Participant’s Signature*

First Last

Date

This field is hidden when viewing the form

Intake Worker’s Signature

First Last

This field is hidden when viewing the form

Date

This project, program or service is funded in whole or in part by the California Dept. of Community Services and Development.

CLIENT TRACKING FORM

SSN#*

Name

First Name Last Name

Date of Birth*

Age*

Address*

Street Address Address Line 2 City State ZIP Code

Telephone*

Household / Applicant Information

Gender*

Male
Female

Disabled*

Food Stamps*

Veteran*

Health Insurance*

Ethnicity*

Education*

Farmers

Farmers
Migrant
Seasonal

Family Type*

Housing*

Rent
Own
Homeless
Other

Income Sources:*

Other Income Source*

Income Amount:*

Household Members Information

Household Member 1

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 2

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 3

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 4

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 5

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 6

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 7

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 8

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 9

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 10

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 11

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 12

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 13

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 14

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 15

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 16

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 17

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

Household Member 18

SSN#*

Name*

First Last

Date of Birth*

Age*

Gender*

Male
Female

Disabled*

Ethnicity*

Education*

Health Insurance*

Veteran*

I certify that this statement is true and correct to the best of my knowledge, and authorize the release of any and all information necessary for verification purposes.

Yo cerifico que esta declaracion es cierta y correcta, y autorizo el uso de esta informacion para proposito de verificasion.

Signature of Client*

First Last

Typing your name here will qualify as your signature.

Date*

Have you received services from any of the programs listed below in the last 120 days?*

HEAP
Fast-Track
Rent Assist.
Shelter

WIC Services
Counseling
Health Services
Mental Health

Disabilities
Transportation
Child Care
CPR/First Aid

Notes/Comments:

Completed Application Form:

Accepted file types: jpg, gif, png, pdf, doc, docx, rtf, txt, Max. file size: 256 MB.

(Energy Intake Form CSD 43)

Current Energy Bill(s):

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, rtf, txt, Max. file size: 256 MB, Max. files: 4.

Income:

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, rtf, txt, Max. file size: 256 MB, Max. files: 39.

Document gross income from the past month for ALL household occupants with income. Examples: paycheck stubs, award letters for SSI/SSA/pensions and unemployment.

Adult Occupants:

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, rtf, txt, Max. file size: 256 MB, Max. files: 30.

Current government-issued photo ID and Social Security Card for all occupants 18 years or older.

Child Occupants:

Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, rtf, txt, Max. file size: 256 MB, Max. files: 39.

Social Security Cards, birth certificates, or immunization records for all occupants younger than 18 years.

Applications from Owners:

Accepted file types: jpg, gif, png, pdf, doc, docx, rtf, txt, Max. file size: 256 MB.

Provide a copy of the deed, title, or property tax papers, as proof of ownership.

Applications from Renters:

Accepted file types: jpg, gif, png, pdf, doc, docx, rtf, txt, Max. file size: 256 MB.

Provide the owner's name, mailing address, and telephone number- MCCAA must contact the owner to complete some mandatory paperwork before we will be able to continue.

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