MCCAC Energy Assistance Application

MCCAC ENERGY ASSISTANCE APPLICATION
PHYSICAL ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHONE:
Format: (000) 000-0000.
MAILING ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMAIL:
example@example.com
TYPE OF DWELLING
See below for answer key
TYPE OF DWELLING:
- H - SINGLE FAMILY HOUSE
- M - MULTI UNIT (2-4)
- U - MULTI UNIT (OVER 4)
- A - MANUFACTURED HOME
- T - TRAVEL TRAILER OR TENT
- R - ROOM RENTAL
RESIDENCE STATUS:
See below for answer key
RESIDENCE STATUS:
- R - RENT (HEAT NOT INCLUDED IN RENT)
- E - RENT (HEAT INCLUDED IN RENT)
- O - OWN
- S - SUBSIDIZED RENT WITH UTILITY ALLOWANCE
- U - SUBSIDIZED RENT WITH HEAT INCLUDED
- W - SUBSIDIZED RENT (NO UTILITY ALLOWANCE)
MAIN HEAT TYPE:
See below for answer key
SECONDARY HEAT TYPE:
See below for answer key
HEAT TYPE:
- E - ELECTRICITY
- O - HEATING OIL
- P - PROPANE
- N - NATURAL GAS
- S - PELLET STOVE
- W - WOOD

Complete for all members of household. Use the key below to complete columns with stars:

Rows	LEGAL NAMES OF ALL MEMBERS OF HOUSEHOLD	DATE OF BIRTH	SOCIAL SECURITY NUMBER	INCOME SOURCE *	GROSS MONTHLY INCOME	INCOME DOCUMENT TYPE*	GENDER*	ETHNICITY*	RACE*	EDUCATION*	DISABILITY (Y/N)	VETERAN (Y/N)	*NON CASH BENEFITS (LIST ALL THAT APPLY): S - SNAP, T - TANF, H - HUD, L - LIHEAP
1
2
3
4
5
6
7
8

*INCOME SOURCE (CHOOSE ONE): WAGES, SSI, SSA, SSB, SSD, TANF, PER CAPITA, UNEMPLOYMENT, CHILD SUPPORT, NONE

*INCOME DOCUMENT TYPE:
- CPS - CHECK PAY STUB
- BVL - BENEFIT VERIFICATION LETTER
- UE - UNEMPLOYMENT DOCS
- DHI - DECLARATION OF HOUSEHOLD INCOME (USE FOR NO INCOME AND/OR CHILD SUPPORT OR IRREGULAR INCOME ON PG. 3)
*GENDER: M - MALE, F - FEMALE, TF - TRANS FEMALE, TM - TRANS MALE, O -OTHER

*ETHNICITY: H - HISPANIC/LATINX, NH - NON HISPANIC/LATINX

*RACE: AA - AFRICAN AMERICAN, NA - NATIVE AMERICAN, AS - ASIAN AMERICAN, NH - NATIVE HAWAIIAN/PACIFIC ISLANDER, HL - HISPANIC/LATINX, W - WHITE, MR - MULTIPLE RACE, R - REFUSED

*EDUCATION (HIGHEST GRADE COMPLETED): 0-8, 9-12, HS - HS GRAD/GED, C - COLLEGE

*NON CASH BENEFITS (LIST ALL THAT APPLY): S - SNAP, T - TANF, H - HUD, L - LIHEAP
ADDITIONAL HOUSEHOLD MEMBERS (Y/N):
IF YES, PLEASE LIST ON A SEPARATE PAPER AND UPLOAD WITH YOUR ATTACHMENTS.
ADULT (AGE 18+) IN HOUSEHOLD WITH ZERO INCOME (Y/N):
IF YES, PLEASE COMPLETE AND SIGN PAGE 3, LIST ALL ADULTS WITH ZERO INCOME ON FORM.
ARE YOUR HEATING UTILITIES INCLUDED IN RENT (Y/N):
IF YES, PLEASE COMPLETE AND HAVE YOUR LANDLORD SIGN PAGE 4.
PRIMARY HEATING UTILITY VENDOR:
NAME ON BILL:
ACCOUNT #
PAST DUE (Y/N)
DISCONNECT NOTICE (Y/N)
SHUT OFF (Y/N)
LIFE-THREATENING CRISIS (Y/N)
SECONDARY HEATING UTILITY VENDOR:
NAME ON BILL:
ACCOUNT #
PAST DUE (Y/N)
DISCONNECT NOTICE (Y/N)
SHUT OFF (Y/N)
LIFE-THREATENING CRISIS (Y/N)
SPLIT PAYMENT (Y/N)
PAGE 1 OF 6

PART 1: APPLICANT NOTICE, PROGRAM DISCLAIMERS, AND APPLICANT RESPONSIBILITIES, WAIVER & RELEASE
Effective 10/01/2022
- I, Applicant, understand that the government energy and weatherization assistance programs are voluntary and my application is subject to a review process to determine my household's eligibility.
- I understand that in order for my household's application to be considered, I must submit a complete application that provides all required information.
- I understand that I may be required to provide additional information or documentation to determine my household's eligibility.
- I understand that my household's application and additional information or documentation materials will all become part of my household's application ("Application").
- I understand that determinations on assistance eligibility are made by the state's Oregon Housing and Community Services (OHCS) department in conjunction with contracted subgrantee agencies ("Subgrantees").
- In the event that my household's Application is denied, I may be entitled to a review of my Application under applicable Oregon Administrative Rules.
- Upon successful enrollment in the LIHEAP/OEAP programs, I further authorize OHCS and the State of Oregon, including designated subcontractors, and OHCS Subgrantees to release my Application and ongoing LIHEAP/OEAP program benefit information held by OHCS (including its subcontractors and OHCS Subgrantees) to the Energy Services Provider (as defined below) for the purposes of administering, monitoring, researching, and evaluating LIHEAP/OEAP program delivery and efficiency.
- I declare that the information I provide to complete my Application is true and correct.
- I agree to comply with the government energy and weatherization assistance program requirements for eligible households.
- I authorize and hold harmless OHCS (including its subcontractors and OHCS Subgrantees) to release my Application and ongoing LIHEAP/OEAP program benefit information up and until one (1) program year following my participation in the LIHEAP/OEAP programs.
- I agree that I am responsible to return ineligible funds or funds used improperly.
- Should I receive any heating and/or cooling equipment as result of my eligibility to these programs, I agree to hold OHCS, its sub-grantees and/or contractors harmless.
PART 2: APPLICANT NOTICE, WAIVER & RELEASE RELATED TO ENERGY SERVICE PROVIDERS & APPLICANT'S ENERGY SERVICE ACCOUNT INFORMATION
- I understand that the State of Oregon, including OHCS, its designated subcontractors, and Subgrantees, may request information related to my energy services account(s) ("Account") from my energy service provider(s), including utility, fuel supplier, vendor, or other similar entity providing similar services ("Energy Services Provider"), once my household applies for energy assistance through one of the energy assistance programs, including but not limited to the Low Income Home Energy Assistance Program (LIHEAP) and Oregon Energy Assistance Program (OEAP).
- I understand that information related to my Account may be requested by the State of Oregon, OHCS, its designated subcontractors, and Subgrantees for the purposes of, including but not limited to, determining my household's energy assistance eligibility, and administering, monitoring, researching, and evaluating the energy assistance programs (all of which as determined by OHCS in its sole discretion).
With my signature,
- I acknowledge that I am the account holder (or the account holder's authorized agent) for the Energy Services Provider Account(s) identified in this Application.
- I hereby authorize and hold harmless my Energy Services Provider(s) to release and provide any and all information relating to my account, including but not limited to account number, account name, service address, billing dates and amounts charged, information related to collections actions, other miscellaneous account charges and information, or other similar account data as may be requested by OHCS or its designated subcontractor (hereinafter "Account Information") to the State of Oregon, OHCS, its designated subcontractors, and Subgrantees. I understand and agree, should I receive any heating and/or cooling equipment as a result of any of these programs, I agree to hold OHCS, it's sub grantees and/or contractors harmless.
- I hereby authorize and hold harmless my Energy Services Provider(s) for such release of my Account Information for up to two (2) energy assistance program years (10/1 to 9/30) prior to my Application and for three (3) program years (10/1 to 9/30) after my Application is submitted.
- I hereby authorize and hold harmless the State of Oregon, OHCS, its designated subcontractors, and Subgrantees in the use (as authorized by OHCS in its sole discretion) of my released Account Information.
PART 3: APPLICANT SIGNATURE
With my signature I hereby provide the required authorization, approval and acknowledgments to both PART 1 and PART 2 of this ENERGY/WEATHERIZATION ASSISTANCE APPLICATION - REQUIRED APPLICANT DISCLOSURES AND APPROVALS.
SIGN HERE
Applicant Signature
Date

MonthDayYear
Date

Review this form and if any of the circumstances apply to any adult over 18, please complete and sign.
DECLARATION OF HOUSEHOLD INCOME
Mid-Columbia Community Action Council
2505 W 7th St
The Dalles, OR 97040
541-298-5131
606 State Street, #1B
Hood River, OR 97031
541-298-5131
Applicant's Name:
This form is to be used for:
Name (Adult 1):
Relationship to applicant:
Name (Adult 2):
Relationship to applicant:
Name (Adult 3):
Relationship to applicant:
Did anyone listed above received any of the following?
Cash payment
If yes; Amount of payment $
Name and phone number of employer:
Financial support for three consecutive months (from someone outside the household)
If yes; Amount of support $
Name and phone number of person providing the support:
Other informal income
If yes; Amount of income $
Source of your informal income:
How do you pay rent/mortgage?
(If additional space is needed, please provide information on a separate piece of paper. If you claim savings, you may be required to produce bank statements. If you state loans, you may be required to produce documentation)
How do you pay for food?
How do you pay for utilities?
How do you pay for any other household expense or personal items?
If you have NO income how long have you had zero income?
What was the source of your last income?
(If employment, please list employer and last date of employment)
Child Support
Child's name:
$
Child's name:
$
Child's name:
$
Child's name:
$
I declare, under penalty of perjury, that the information I provided to complete this application is true and correct.
Signature:
Date:

MonthDayYear
Date

UPLOAD IDENTIFICATION FOR ALL ADULTS,
SOCIAL SECURITY CARDS (IF AVAILABLE) FOR EVERYONE IN HOUSEHOLD

If you are experiencing difficulty uploading documents or need to submit additional documents, please email Lharris@mccac.com
File Upload

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UPLOAD A COPY OF YOUR HEATING BILL OR BULK FUEL RECEIPT

If you are experiencing difficulty uploading documents or need to submit additional documents, please email Lharris@mccac.com
File Upload

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UPLOAD PROOF OF INCOME FOR ALL ADULTS
ALL INCOME RECIEVED IN THE PAST 30 DAYS
- BANK STATEMENTS MAY NOT BE USED-

If you are experiencing difficulty uploading documents or need to submit additional documents, please email Lharris@mccac.com
File Upload

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UPLOAD ANY ADDITIONAL DOCUMENTS - AS NEEDED
File Upload

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Should be Empty:

PART 1: APPLICANT NOTICE, PROGRAM DISCLAIMERS, AND APPLICANT RESPONSIBILITIES, WAIVER & RELEASE

PART 2: APPLICANT NOTICE, WAIVER & RELEASE RELATED TO ENERGY SERVICE PROVIDERS & APPLICANT'S ENERGY SERVICE ACCOUNT INFORMATION

PART 3: APPLICANT SIGNATURE

DECLARATION OF HOUSEHOLD INCOME

Child Support

LANDLORD LETTER