Utility Assistance Application

LIHEAP Application

1235 W. Main Street, Merced CA 95340 | (209) 723-3201
Read the following information in its entirety to ensure that you provide an accurate and complete application. Please provide information and documents for everyone residing in the home for which assistance is being requested.

The following information will go over in detail the information obtained for each required document in the application.

CSD 43 Application Form: “Primary Applicant” will be listed on this form and will be Household Member 1 throughout the application packet.

All Household Members’ information must be filled out for every person residing in the home.

First Name, Last Name, Relationship to applicant, DOB, Gender, Race, Hispanic/Latino, Amount of Gross Monthly Income, Source of Income. If anyone in the household does not obtain income, please note the $ amount as zero and source as none.

Conservation of Energy Form: Please select either “yes” or “no” for a Weatherization Referral. Weatherization Services include but are not limited to weather stripping, window repair/replacement, appliance upgrade to energy efficient ones, water heater repairs/replacement, Heating/Cooling repair/replacement, ceiling, floor, and wall insulation.

*Due to the overwhelming demand of the Weatherization Program wait time can be estimated from 6months – 12months and not all eligible households will be weatherized*

CSD 081 Form: Please have PG&E, MID, TID, or Propane Account Holder Sign this form.

*If the account is listed in someone else’s name, please note that you will have to obtain account holders signature and then submit form separately*

Financial Management Counseling Form: Provide all your monthly financial obligations. If you do not have an expense for a category DO NOT leave blank, please note the amount as $0.

Section 4 "Problems": Please explain your hardship or reason you need utility assistance.

Client Tracker Form: Requires Social Security #’s, Last Name, First Name, DOB and AGE, Disabled (yes or no), Education (highest level) per household member, Health Insurance, (Medical, Medicare, Employer Based, etc.) and Veteran (yes or no).

A blank application will NOT be accepted, please ensure to fill out all information required.
*All applications/verifications will be processed in order received*
Inaccurate and/or missing information may delay the processing of your application.

PLEASE UPLOAD COPIES OF THE FOLLOWING DOCUMENTS WITH YOU APPLICATION *SCREENSHOTS OF DOCUMENTS ARE NOT ACCEPTABLE*

GOVERNEMENT ISSUED ID FOR ALL ADULTS 18YRS AND OLDER IN HOUSEHOLD: IF STATE ID FOR ANY INDIVIDUAL STATES “FEDERAL LIMITS APPLY” PLEASE ALSO UPLOAD A COPY OF US BIRTH CERTIFICATE, U.S. PASSPORT, OR DOCUMENT TO CONFIRM PERMANENT RESDICENCY OR CITIZENSHIP FOR EACH ADULT. *DOCUMENTS HAVE TO BE VALID, CANNOT BE EXPIRED*

ALL PAGES OF CURRENT ENERGY BILLS: MUST SHOW ACCOUNT NUMBER, NAME, PHYSICAL ADDRESS, BILLING DATE & DUE DATE, CURRENT CHARGES & ANY PREVIOUS BALANCE. (48 HR NOTICES AND DELINQUENT NOTICES WILL NOT BE ACCEPTED.)

PLEASE UPLOAD ALL PAGES OF YOUR ENERGY BILLS. If you have both MID or TID (electric) and PG&E (gas), please upload copies of both bills. If you have both propane (gas) and PG&E (electric) please upload both bills.

SOCIAL SECURITY CARDS: For EVERYONE LIVING IN THE HOUSEHOLD INCLUDING CHILDREN. (MEDI-CAL CARDS, IMMUNIZATION RECORDS, OR BIRTH CERTIFICATE WILL BE ACCEPTED FOR MINOR CHILDREN ONLY, BUT SSC PREFERRED)

CURRENT PROOF OF INCOME FOR THE LAST 4 Weeks for EVERYONE IN HOUSEHOLD:

o Wages earned from employment please provide current copy of pay stub(s) covering most recent 4 weeks of gross income before deductions if multiple stubs, they must be consecutive.
o Social Security Income please send a copy of Current Social Security Award Letter, or Most recent copy of bank statement (all pages) showing direct deposit reflecting name of the person receiving SSA benefits, or a copy of the most recent Social Security Income check.
o Pension/Retirement Income please provide a copy of check stub or current award letter.
o Unemployment benefits Income please provide current check stubs (must be consecutive), or current printout that reflects name of person receiving benefits, or current award letter.
o Workers Compensation Income please provide copy of current check stubs(s), current award letter.
o Self-employment and/or Rental Income please provide Entire Current Year’s tax filing must include Schedule 1, Schedule C , and/or Schedule E.
o Public assistance TANF/CALFRESH Benefits please provide current Verification of Benefits for everyone receiving assistance, if multi-generational household reside in same home please ensure that a Verification of Benefits is submitted for each individual case.
o Child support Income please provide copy of most current monthly statement, or printout.
- 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 support along with their full contact information, signature , and date letter was written. Please note the letter must reference the name(s) of the child(ren) for which the support is being provided for.

PROOF OF INCOME MUST BE CURRENT WITHIN THE LAST 4 WEEKS from the date the application is signed and submitted.

FOR CALFRESH/CALWORKS HOUSEHOLD ONLY:

PLEASE PROVIDE CalFresh/CalWORKs Verification of benefits for CURRENT MONTH

o A Declaration/Written statement attesting to income from everyone in Household who has obtained income within the last 4 weeks must be detailed per household member.
o If any members of the household do not have income, please state that.

Example of Declaration/Written statement-
I (Name), received $(gross) in the last four weeks from: (Source)
*If you submit Verification of Benefits along with the declaration of income, please DO NOT submit proof of income*
Please check this box to verify you have read these disclaimers fully.*

I have read the disclaimers and all instructions and information fully.
Application Date

MonthDayYear
Date

Rows	Number of people
Ages 0 - 2 Years
Ages 3 - 5 Years
Ages 6 - 18 Years
Agent 19 - 59
Ages 60 and older
Disabled
Native American
Seasonal or Migrant Farmworker

Rows	Monthly Income
TANF / CalWORKs
SSI / SSP
SSA / SSDI
Paycheck(s)
Interest
Pension
Other

LIHEAP Energy Conservation Education

MCCAA Energy / Weatherization Dept. | 1235 W. Main St. - PO Box 2085, Merced CA 95340
Participant*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number
I would like a Weatherization Referral*

YesNo
Signature of Participant*
Date

MonthDayYear
Today's date
Weatherization Customer Agreement
Thank you for applying for the Merced County Community Action Agency (MCCAA) Weatherization Program. Our goal is to help you save energy (and money), and help make your home safer and more comfortable. In order to make our visits to your home safe for both your family and the Weatherization staff, you must read and sign this document before MCCAA will begin any weatherization work on the property.

The Weatherization staff will be performing work on the outside and inside of your residence. In order to minimize the risk of loss to you and to MCCAA please observe the following during all visits to your home by MCCAA Weatherization staff.
1. MCCAA is not responsible for any lost, stolen, missing, or misplaced items during any of our visits to your home. It is your responsibility to secure any items or personal belongings of value. If you have any questions as to what parts of your home the staff will need access to, please ask.
2. Please keep all pets away from areas where the weatherization staff will be working. You will need to secure your pets during the entire visit. The staff will need to be able to come in and out of doors and gates and are not responsible for watching out for your pets. Please note that doors, gates, and windows may need to remain open while the crew is performing certain work.
3. Please make sure that children who are present during our visits are under your supervision at all times and kept away from the areas where staff members are working. Do not allow children to be left unsupervised in areas where the weatherization staff is working, in or around MCCAA vehicles, or near any tools, equipment, ladders, and extension cords.
4. An adult resident must remain present at the home while MCCAA staff is
  working. Staff members are not allowed to remain on your property without an adult resident present.
We thank you for your cooperation. Should you have any questions, please contact the MCCAA Weatherization Department at (209) 723-1225.
Landlord Name
Phone Number
Please enter a valid phone number.
Please Select one.

Homeowner, provide proof of ownership (mortgage statement, deed, or most recent property tax statement)Renter, please provide landlord contact information
Signature of Participant*
Date

MonthDayYear
Today's date
LIHEAP Applicant Financial Management Counseling

MCCAA Energy / Weatherization Dept. | 1235 W. Main St. - PO Box 2085, Merced CA 95340
Participant*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number
Name of Program in which assistance is being requested
1. Monthly Household Income
Source(s) of Income*
Must reflect the same income sources listed on intake form 43b (Pg. 1)
b. Gross Monthly Income*
c. Net Monthly Income*
After deductions
2. Monthly Financial Obligations

Monthly bills paid by applicant*

Rows	Amount
a. Rent / Mortgage Payment
b. Food Expenses (out of pocket)
c. Household Expenses (toiletries)
d. Credit Card Payment
e. TV / Cable Payment
f. Telephone Payment
g. Water / Garbage Payment
h. Utility Payment
i. Transportation Expenses
j. Car Payment

k. Other Monthly Payments (be specific)
Payment Type
Amount
Payment Type
Amount
Payment Type
Amount
GRAND TOTAL*
3. Possible available cash after all monthly obligations are paid*
4. Problems
Why does applicant need financial assistance from MCCAA?*
5. Utility Company

Specify what Utility is to be paid
Utility Company To Be Paid*
Participant's Signature*
Date

MonthDayYear
Today's date
This project, program or service is funded in whole or in part by the American Recovery and Reinvestment Act of 2009 in cooperation with the California Dept. of Community Services and Development.

CSD Form 081 | Authorization and Consent Form

Department of Community Services and Development (Rev. 12/2017)
ACCOUNT HOLDER NAME AND MAILING ADDRESS
Is the Account Holder also the Applicant?*

YesNo
Account Holder Name*

First NameMiddle NameLast Name
Account Holder Address*

Street Address

Unit Number (if any)

CityState / Province

Postal / Zip Code
Is the utility service address the same as the account holder’s mailing address?*

YesNo
Full Name of Applicant for Benefits (from Form 43)*

First NameMiddle NameLast Name
Utility Service Address*

Street Address

Unit Number (if any)

CityState / Province

Postal / Zip Code
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 2nd Utility Company (if any)
Service Account Number
AUTHORIZATION AND CONSENT
By signing this form, you (Account Holder) give your authorization and 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 property’s utility account, meter usage and energy consumption data, and other information as needed for the period beginning 24 months prior to, and continuing for 36 months after, the date signed below. The information you authorize us to obtain and share will be used for the purposes of evaluating home energy usage of program beneficiaries 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. CSD, its contractors, consultants, other federal or state agencies and affiliated programs (CSD Partners), working cooperatively with your utility company and its contractors, use this information to provide services that assist low-income families, such the applicant, to pay their home energy bills and manage those energy needs for the purposes stated in this Authorization.
Signature*
Date

MonthDayYear
Today's date
REVOCATION OF AUTHORIZATION AND 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.
APPLICABLE 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

Upload Files to Complete Application
Our Utility Assistance programs are NOT emergency response programs. We schedule on a first come, first serve basis for anyone who is prequalified at the time of screening. If any documentation is missing upon submission, there may be delays in processing your application.

If you have any questions about this application, please call us at (209) 723-3201.
Current Photo ID (Real ID)

For ALL adults living in the household (18 years of age and older). If ID's states Federal limits apply, please also upload US Birth Certificate, US Passport, Naturalization Certificate N-550 or N-570, Permanent Residency, American Indian card with a classification code KIC, or document of direct receipt of SSI or SSA benefits.
Adult Occupants:*

Max. file size: 256 MB
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Current ID For Minors

Social Sercurity Cards, Medi-Cal cards, birth certificates, or immunization records will be accepted for all occupants younger than 18 years.
Child Occupants:*

Max. file size: 256 MB
Cancelof
Social Security Cards

For everyone living in the household. (Medi-Cal cards, shot records and birth certificate will be accepted for children only).
Social Security Cards:*

Max. file size: 256 MB
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Current Energy Bill(s)

(PG&E, TID, MID, Propane, Wood, etc.) MUST show account number, name, physical adderss, billing date & due date, total current charges & any previous balance. Late notices (48 hour notices) will not be accepted.
Current Energy Bill(s):*

Max. file size: 256 MB
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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**
CalFresh / CalWorks Benefits:*

Max. file size: 256 MB
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Income

Document gross income from the past month for ALL household occupants with income.

Examples: paycheck stubs, award letters for SSI / SSA / Pensions, and unemployment.
Income:*

Max. file size: 256 MB
Cancelof
Should be Empty:

LIHEAP Application

Read the following information in its entirety to ensure that you provide an accurate and complete application. Please provide information and documents for everyone residing in the home for which assistance is being requested.

CSD 43 | Energy Intake Form

Household Information

HOUSEHOLD MEMBERS

APPLICANT (HOUSEHOLD MEMBER 1)

PAY BILL

WOOD, PROPANE or FUEL OIL SERVICE (WPO)

ENERGY INFORMATION

LIHEAP Energy Conservation Education

Weatherization Customer Agreement

LIHEAP Applicant Financial Management Counseling

1. Monthly Household Income

2. Monthly Financial Obligations

4. Problems

5. Utility Company

Client Tracker Form

APPLICANT (HOUSEHOLD MEMBER 1)

CSD Form 081 | Authorization and Consent Form

ACCOUNT HOLDER NAME AND MAILING ADDRESS

UTILITY INFORMATION

AUTHORIZATION AND CONSENT

REVOCATION OF AUTHORIZATION AND CONSENT

APPLICABLE PROGRAMS

Upload Files to Complete Application

Current Photo ID (Real ID)

Current ID For Minors

Social Security Cards

Current Energy Bill(s)

Verification of CalFresh / CalWorks Benefits for Current Month

Income