YOU MUST CONTINUE TO PAY YOUR BILL DURING APPLICATION REVIEW

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1 LIHEAP WEATHERIZATION AND UTILITY ASSISTANCE PROGRAMS ONLINE APPLICATION INSTRUCTIONS (Please read ALL instructins BEFORE yu fill ut the applicatin) Yu may qualify fr utility assistance thrugh the LIHEAP prgram and als fr n-cst Weatherizatin f yur hme r rental unit. Eligibility fr these prgrams requires that yu first meet the incme guidelines Final eligibility is determined nly after receipt f the cmpleted applicatin and required dcuments. Incmplete r unsigned applicatins will NOT be prcessed. Cmpleted applicatins will be cmpared with thse f ther applicants t determine the greatest need based n the fllwing criteria: Husehld incme. Number and age f individuals in the husehld. Ttal mnthly energy csts (gas, electricity, wd, prpane & il.) Frail, elderly and life-threatening (medical prf required) cnditins. Utility assistance is prvided ONE TIME per prgram year. Funding is limited. Nt all incme-qualified individuals will be assisted. If an applicant qualifies, the applicatin prcess, frm receipt f applicatin t payment, takes apprximately 90 Days. YOU MUST CONTINUE TO PAY YOUR BILL DURING APPLICATION REVIEW T apply fr assistance, yu must cmplete the attached applicatin. Yu may fill the frm ut nline, print, scan and it t: r yu can fill ut the frm nline then print and mail it t: Utility Assistance Cmmunity Actin Partnership f Orange Cunty Mnarch Street Garden Grve, CA If yu d nt fill ut the frm nline, print clearly utilizing an ink pen. D nt use a pencil. CLICK ON THIS LINK TO OPEN APPLICATION FORM: FORM INSTRUCTIONS BY SECTION---USE THE TAB KEY TO MOVE THROUGH EACH SECTION SECTION ONE: Fill ut this sectin with the , NAME, ADDRESS, DATE OF BIRTH, and SOCIAL SECURITY NUMBER f the persn applying. Please als list whether yu are an OWNER r RENTER, the DATE LAST ASSISTED, NUMBER OF TIMES ASSISTED, and the LANGUAGE yu speak. SECTION TWO: List ALL peple living in the husehld, INCLUDING YOURSELF. Mark hw many are in each age grup r classificatin. SECTION THREE: List the number f hw many peple in the husehld receive incme and enter the GROSS (ttal BEFORE Taxes) INCOME under each type (i.e. TANF $2000)

2 PROOF OF INCOME MUST COVER THE LAST 4 WEEKS FROM APPLICATION DATE AND COVER A FULL MONTH ACCEPTABLE Temprary Assistance fr Needy Families (TANF): Ntice f Actin, cmputer printut, benefit letter, cpy f welfare check. Date if Dcument must be within 30 Days. Supplemental Security Incme: (SSI) Ntice f Planned Actin r Frm 2458, cmputer printut frm Scial Security Office, cpy f bank statement shwing SSI direct depsit, cpy f SSI check. Award Letter indicating incme fr current year. Scial Security: cpy f current check(s), SSA Frm 4926, r 2458, cmputer printut frm Scial Security Administratin Office, Bank Statement shwing direct depsit,. Pensin and Annuities: cpy f a current check, verificatin n letterhead r annual statement frm pensin plan. Wages: Cpy f current paycheck stub(s) cvering a nemnth perid and shwing grss incme. Interest Incme: mnthly r quarterly bank statement, statement f interest incme frm bank r agency. Disability Cmpensatin: cpy f a current check, printut r letter frm agency r insurance cmpany verifying the cmpensatin amunt. Unemplyment Benefits: cpy f current checks(s), printut frm Emplyment Develpment Department. Child and/r Spusal supprt: cpy f current check. Supprt frm an Individual: cpy f check and statement signed by persn prviding the supprt. General Assistance: Ntice f Actin frm Cunty Scial Services, cpy f a current check. Veteran s Benefits: letter indicating receipt f Veteran s Pensin, cpy f Veteran s Administratin check. Signed Federal Tax Frm 1040 (valid thrugh April 15, 2011): WILL ONLY BE ACCEPTED FOR SELF-EMPLOYED. NOT ACCEPTABLE Capital Gains. Adptin Assistance. Fster Grandparents and Senir Cmpanin Prgrams. Educatinal assistance - Student incme grants lans Pell grants. Any Assets Withdrawn frm a Bank. Draw dwn frm Reverse Mrtgages. The Sale f Prperty (Car r Huse). Tax Refunds. Gifts. Lans. Lump-Sum Inheritances. One-Time Insurance Payments. Cmpensatin fr Injury. Emplyer r Unin Paid Prtin f Health Benefits. Fringe Emplyee Benefits. Withdrawal frm Savings. Medical Stickers. Fd Stamp with NO dllar amunt. Fd r Husing Received in Lieu f Wages. Federal Nn-case Benefit Prgrams (Medicare, Medicaid, Schl Lunches, and Husing Assistance). W2 Frms and Medi-Cal cards are nt accepted as prf f incme. SECTION FOUR: Utility Cmpany Name Please check the bx f the Utility Cmpany bill that yu wuld like paid r if this is in included in yur rent check that bx stating this. Then list the ACCOUNT NUMBER fr the cmpany that yu need assistance with and the NAME OF THE PERSON ON THE BILL fr that cmpany. SECTION FIVE: Check all the services that yu are interested in receiving. (See DESCRIPTION OF SERVICES) SECTION SIX: Include the fllwing infrmatin fr each(please start the list with the name f the Utility Cmpany bill yu wuld like PAID): YOU WILL NEED COPIES OF CURRENT GAS AND ELECTRIC BILL SHOWING LAST 4-WEEKS OF USAGE, FROM THE DATE OF THIS APPLICATION. (N pening, clsing, r utdated utility bills.) Billing Perid: This includes the starting date and ending date, fr example 10/10/12 t 11/16/12. Please nte that there must be a minimum f 22 days billed. New Charges: This is just the current amunt and DOES NOT INCLUDE a PAST DUE amunt. Yur new charges may nt match yu TOTAL DUE if there is a Past Due amunt. It is imprtant yu put nly NEW CHARGES in this clumn. Ttal Due: This amunt may be different frm yur NEW CHARGES if there is a Past Due r a Credit n yur accunt. If yur bill has a CREDIT yu will NOT QUALIFY fr the prgram. The next few pages include samples f the different utility cmpany bills and where yu can lcate the infrmatin needed fr the applicatin. Yu will find the infrmatin circled in RED. SECTION SEVEN: THE NAME, AGE, AND INCOME (IF OVER 18 years f age) OF ALL persns living in the husehld at the time f applicatin. please als check if they are disabled r nt. START THE LIST WITH YOUR NAME. (Yu may put friend, renter, r tenant if nt related) SECTION EIGHT: SIGN yur name and DATE

3 COMMUNITY ACTION PARTNERSHIP OF ORANGE COUNTY Weatherizatin and Utility Assistance Frm 2012 First Name Middle Initial Last Name Date f Birth Address SECTION ONE Unit Number Mnth Day Year Scial Security Number City Zip Phne Owner Renter Date Last Assisted Number f Times Assisted Language Spken Peple Living in Husehld Enter the TOTAL number f peple living in the husehld including yurself Enter the number f peple wh are: 2 years ld r yunger SECTION Ages 3 5 years Ages years TWO Ages (Adult) Ages 60 r lder (Elderly) Disabled Native American Limited English Speaking Seasnal r Migrant Farmwrker Incme TOTAL INCOME Enter the TOTAL number f husehld members wh receive Incme Enter ttal GROSS* mnthly incme frm all peple living in the husehld including surce: TANF SSI/SSP SSA/SSDI Paycheck (s) Interest Pensin Other SECTION THREE PLEASE CHECK WHICH UTILITY BILL WOULD YOU LIKE PAID (CHOOSE ONLY ONE) EDISON SOUTHER CALIFORNIA GAS ANAHEIM UTILITIES SDG&E ACCOUNT NUMBER Name f Custmer n Utility Bill: Frm the Descriptin f Services n the instructin page, please check which services that yu are interested in receiving: SECTION FIVE Utility Assistance (HEAP) Fast Track Assistance Weatherizatin Refrigeratr ECIP Please list yur CURRENT (last 30 days) Utility Cmpany charges. If yu are seeking Utility Assistance please start with the bill yu wuld like assistance n. Utility Cmpany Billing Perid New Charges Ttal Due SECTION SIX TO TO TO TO Ttal New Charges $ CLIENT SIGNATURE: Check here if yur utilities are included in yur rent r sub metered List EVERYONE including yurself wh currently live in the same dwelling (if n ne else, write NONE under yur name) All persns living in the huse that are 18 years ld r lder MUST prvide prf f incme r fill ut DECLARATION OF NO INCOME frm (attached) Use a separate sheet fr additinal names. HM FIRST NAME MI LAST NAME AGE RELATION TO ME (IF OVER 18) TYPE OF INCOME PERMANENTLY DISABLED 1 YES NO SECTION SEVEN SECTION FOUR 2 YES NO 3 YES NO 4 YES NO 5 YES NO 6 YES NO SECTION EIGHT DATE:

4 Accunt Number New Charges Ttal Due

5 New Charges Billing Perid and number f days

6 The Gas Cmpany Online Bill Accunt Number Must Click This Optin T Print Online Billing Perid and number f days Ttal New Charges Ttal Due

7 Break dwn utility cst if utilities are included in rent

8 As a nt-fr-prfit agency, ANAHEIM PUBLIC UTILITIES cntinues t ffer residential rates 20 t 40% lwer than cmpeting utility prviders. Belw is a breakdwn f the key charges yu will see n yur bill. T get a true cmparisn f yur cst savings, please remember that this bill typically cvers a tw-mnth perid and encmpasses charges fr paramedic service, sewer, trash pick up, street sweeping, water, electric and ther services. 1. Custmer Infrmatin Yur name, service lcatin, and blck number are lcated here. Yur blck number refers t a gegraphic sectin f the City primarily used t identify areas that may be impacted by rtating blackuts when they are rdered by the agency cntrlling Califrnia s electric grid system. 2. Accunt Infrmatin Custmer accunt number is the CUSTOMER ID- LOCATION ID (xxxxxx-xxxxxx). Yur next meter read date and accunt identificatin numbers are lcated here. Each custmer has tw types f accunt identificatin numbers. First, there is a CUSTOMER ID that is specific t a persn that established the accunt. The secnd is a LOCATION ID that is assciated with yur service address. 3. Meter Reading Summary Yur electric and/r water meter read infrmatin fr the billing perid is lcated here, including the billing dates f service, number f days in the billing perid, meter number, the previus and current meter readings. Ttal cnsumptin fr electric is reflected as kilwatt-hurs r kwh (ne 100 watt light bulb burning fr ne hur equals 0.1 kwh,) and water is reflected in hundred cubic feet r HCF. (One HCF equals 748 gallns). 4. Summary f Current Charges Yur electric and water charges fr the billing perid are lcated here. Mst residential custmers will see the fllwing electric charges: Custmer Charge- base charge fr prviding a meter and assciated services, such as meter reading and custmer services. 5. Yearly Cmparisn 6. Other Charges 7. Ttal Charges Yur ttal charges and balances fr the current tw mnth perid can be fund here. 8. Imprtant Infrmatin This sectin displays imprtant messages frm the City f Anaheim. Review this sectin t learn mre abut yur accunt r Anaheim prgrams. 9. Payment Stub Find ut hw much yu we and when payment is due. Remember that bills can be paid by mail, via telephne, thrugh Pay Online, in persn at 201 S. Anaheim Blvd, thrugh the after-hur drp-ff bx at that same lcatin.

9 Use the fllwing check list t make sure yu have all the infrmatin needed if yu are scheduled fr an appintment. If yu cme t a scheduled appintment withut the required dcuments yu will be rescheduled. CHECK ALL BOXES THAT APPLY Current Utility Bills With Billing Perids: Must Have Bth Bills Even Thugh We Are Only Assisting With One. 1 st Current Bill Needing Assistance (If Applicable: Past Due r Discnnect Ntice), 2 nd Bill Original Current Bill Only. If All Electric: Original, Current Electric Bill If Utilities are included in RENT, UTILITY NOTICE frm Landlrd Valid Califrnia Picture ID and Prf f Birth Date Califrnia Drivers License Passprt Birth Certificate DMV ID Renters Agreement (fr Weatherizatin) authrizing weatherizatin wrk t be dne. Hmewner Pht ID with the Prperty Tax Bill. Scial Security Card: r Legal Dcument with applicant s name and SS#. Prf f All Incme, Current frm the Last 30 Days: Applies t All Husehld Members with Any Incme frm the Age f 18 years and Older. Temprary Assistance fr Needy Families (TANF): Ntice f Actin, cmputer printut, benefit letter, cpy f welfare check. Date if Dcument must be within 30 Days. Supplemental Security Incme: (SSI) Ntice f Planned Actin r Frm 2458, cmputer printut frm Scial Security Office, cpy f bank statement shwing SSI direct depsit, cpy f SSI check. Award Letter indicating incme fr current year. Scial Security: cpy f current check(s), SSA Frm 4926, r 2458, cmputer printut frm Scial Security Administratin Office, Bank Statement shwing direct depsit,. Pensin and Annuities: cpy f a current check, verificatin n letterhead r annual statement frm pensin plan. Wages: Cpy f current paycheck stub(s) cvering a ne-mnth perid and shwing grss incme. Interest Incme: mnthly r quarterly bank statement, statement f interest incme frm bank r agency. Disability Cmpensatin: cpy f a current check, printut r letter frm agency r insurance cmpany verifying the cmpensatin amunt. Unemplyment Benefits: cpy f current checks(s), printut frm Emplyment Develpment Department. Child and/r Spusal supprt: cpy f current check. Supprt frm an Individual: cpy f check and statement signed by persn prviding the supprt. General Assistance: Ntice f Actin frm Cunty Scial Services, cpy f a current check. Veteran s Benefits: letter indicating receipt f Veteran s Pensin, cpy f Veteran s Administratin check. Signed Federal Tax Frm 1040 (valid thrugh April 15, 2011): WILL ONLY BE ACCEPTED FOR SELF-EMPLOYED Other: (describe)

10 DESCRIPTION OF SERVICES Utility Payment Assistance Once-a-year assistance with paying a cstly energy utility bill is available t incme qualified Califrnia husehlds under the Lw-Incme Hme Energy Assistance Prgram Hme Energy Assistance Prgram (HEAP) prvides a direct payment t an eligible client s utility bill t help ffset the cst f heating r cling their hme. Fast Track prvides a direct payment t an eligible client s utility bill if there the client is in a crisis situatin; such as receiving a 24 r 48 hur discnnect ntice, r service terminatin by a utility cmpany, r an energy-related crisis r life-threatening emergency existing in the husehld. Weatherizatin Prvides free energy efficiency upgrades t the dwellings f lw-incme families t lwer their mnthly utility bills. Hmes may nly be weatherized ONE time in the life f the hme. Yu d nt have t wn yur hme t be eligible. Renters that qualify must have permissin frm their Landlrd (see attached frm CSD 515) Weatherizatin fr single family hmes, apartments, cnds and mbile hmes. Imprvements such as repair t heating and cling systems, duct wrk, insulatin, refrigeratr, shwer heads, faucet aeratrs, CFL light bulbs and mre may be available after the dwelling is assessed fr qualifying measures. Energy Crisis Interventin Prgram (ECIP)/HCS (Heating and Cling Services) prvides assistance t lw-incme husehlds that are in a crisis situatin with either a furnace r water heater.

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