Low Income Home Energy Assistance Program (LIHEAP) I, __________________________________, who applied for the LIHEAP Program on _____/_____/_____, understand that this is not an emergency program, and it may take three (3) to four (4) months before a credit appears on my utility bill. I also understand that due to a high demand of applications that will be processed this year and requirements of the State of California to prioritize applications; I may not be assisted during this contract year. If this should be the case Inyo Mono Advocates for Community Action will notify me in writing within ninety (90) days, after I have submitted my application.

Applicant Signature: ________________________

Date: _____/_____/_____

In-take Signature: __________________________

Date: _____/_____/_____

Low Income Home Energy Assistance Program (LIHEAP)

Due to the rules and regulations of the State of California my application will only be valid for 30 days. I will make sure to thoroughly read, fill out and submit all required documentation within this time frame. If my application is incomplete, IMACA will return my application with details of the missing items needed to have a complete application. I will have 15 days to submit any missing information along with my application or it will be void and I will need to restart the whole process again. Approval for assistance is based upon a priority point system which includes points for household income, energy burden, and vulnerable population (elderly, disabled and small children in the family). Due to the high volume of inquiries for LIHEAP Assistance I will take into consideration that there is no guarantee that I will receive assistance. The LIHEAP Program is not an emergency program, and it may take three (3) to four (4) months before a credit appears on my utility bill. Due to a reduction of applications that will be processed this year and requirements of the State of California to prioritize applications; I may not be assisted during this contract year. If this should be the case Inyo Mono Advocates for Community Action will notify me in writing within ninety (90) days, after my application is submitted.

Rev. 5/2014

2014 IMACA LIHEAP Application (Low Income Home Energy Assistance Program) USE BLUE OR BLACK INK ONLY! NO WHITE OUT • DON’T FORGET TO SIGN YOUR APPLICATION! • SKIP SHADED AREAS

____________________________ APPLICANT NAME (Please Print)

______________ DATE

*****PLEASE READ THOROUGHLY***** PLEASE SELECT ONLY ONE TYPE OF ENERGY ASSISTANCE: PROPANE

ELECTRIC

WOOD

PELLETS

OIL/KEROSENE

TO APPLY FOR SERVICES, PLEASE RETURN ALL OF THE FOLLOWING DOCUMENTS:  UTILITY SHUT-OFF OR DELINQUENT NOTICES  If applicable  UTILITY STATEMENTS (MOST RECENT) FOR ALL HOME UTILITIES  Submit statements for ALL utilities used in the home  Include ALL pages  Statements must be within 30 days of the application date  Statements must show: □ customer’s name

□ service address

□ account number

□ energy usage

□ cost

□ one full month of service

 Propane and Kerosene Customers: Please ask your propane/kerosene provider for an Account Activity Printout that shows the information listed above PLUS all account activity from the date of your last tank fill through the present.  INCOME DOCUMENTATION FOR ALL HOUSEHOLD MEMBERS  One full month of current documents  Documents must be dated within 30 days of the application date  ALL sources of household income for ALL household members must be documented

How many members 18+ yrs. receive the following: ___ Pay Stubs ___ Social Security ___ Annuity ___ Self-employment

___ Unemployment Stubs ___ Pension ___ Child Support ___ Rental Income

___ TANF ___ General Assistance ___ Disability ___ No Income

___ SSI ___ VA Benefits

 BANK STATEMENTS  Required for ALL open and active accounts  Please submit for anyone 18 years of age or older who have an open account  Must have all pages to the statement ALL DOCUMENTS MUST BE CURRENT TO WITHIN 30 DAYS OF THE APPLICATION DATE! APPLICATIONS NOT CURRENT TO WITHIN 30 DAYS OF THE APPLICATION DATE WILL NOT BE ACCEPTED.

PLEASE DO NOT REMOVE PAGES!

Rev. 5/2014

SERVICE ACCEPTANCE STATEMENT Initial after Reading each statement:

I understand that: ____ Neither I nor anyone in my household has received energy assistance from any other organization in the current LIHEAP PROGRAM YEAR. ____ The assistance I am applying for is not immediate. It may take up to 3 months to receive assistance. ____ I am responsible for paying my utility bill until I receive a credit on my utility account. ____ Incomplete applications will not be accepted. ____ I have 15 days to submit any missing documents with my application. ____ The assistance is for the address written on the application. If I move my application will be voided and I will need to fill out a new application. ____ The money IMACA credits to my account is only for the utility that I applied for. If I close the utility account and there is a credit on the account, I cannot receive nor transfer the money. ____ My household may only receive assistance for ONE utility per program year (not including Weatherization). ____ If I provide false information, or withhold information, my application will be denied. ____ By accepting wood/pellets/oil-kerosene for my household’s use I am certifying that my primary source of heat is wood/pellets/oil-kerosene. Any other use or sale is prohibited and may be actionable under the Energy Crisis Intervention Program. ____ Applying for assistance does not guarantee that I will receive assistance. My household must meet eligibility requirements and assistance is subject to availability of funding. ____ CONFIDENTIALITY: My file will be kept confidential. All information collected by IMACA will be used to determine eligibility, provide service, and for reporting purposes as required by law and/or program contract requirements. The information I provide in my application will not be shared with any persons not listed on my application with the exception of reporting agencies and those agencies listed on the Authorization for Release of Information. If I request any information to be shared with other agencies or persons, I must submit my request in writing. ____ IMACA does not discriminate in the provision of services on the basis of race, color, national origin, disability, age, or sex. ____ If I feel that any action is unfair, I have the right to appeal. By signing this form, I affirm that I have read and understand the agreement.

________________________________ APPLICANT SIGNATURE

__________________ DATE

0 0 0 0

Department of Community Services and Development Energy Intake Form

Priority Points:

CSD 43 (5/2014)

Job Control Code Intake Initials:

Agency: Inyo Mono Advocates for Community Action First Name Middle Initial

A.C.C.

Eligibility Cert Date:

Intake Date:

Last Name

Date of Birth M

Mailing Adddress Mailing City

Mailing County

Mailing State

D

Y

Y

Mailing ZIP Code

Service Address (Do not use P.O. Box)

Unit Number

Service City

Service County

Service State CA Telephone Number: ( )

Social Security Number (SSN): Enter the total number of people living in the household, including the applicant 

D

Unit Number

Check if same as service address

PEOPLE LIVING IN HOUSEHOLD

M

Only?

Income

Service ZIP Code Message

UTILITY BILL DISCOUNT You may be eligible for a discount on your monthly utility bill Contact your local utility company and ask about reduced rate programs.

Enter the total number of household members who receive income

Which utility company do you want paid?

Enter the number of people who are: 2 years old or younger Ages 3 – 5 years

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

TANF $ SSI/SSP $ SSA/SDI $ Paycheck(s) $ Interest $ Pension $ Other $ TOTAL INCOME $

Ages 6 – 18 years Ages 19 – 59 (Adult) Ages 60 or older (Elderly) Disabled Native American Limited-English Speaking Seasonal or Migrant Farmworker

Account Number:

Name of customer on the utility bill:

Check here if your utilites are included in rent or sub-metered.

Check here if utilities are all electric

1. What is the main fuel you use to HEAT your home? (SELECT ONLY ONE) Natural Gas Propane Wood Electricity Fuel Oil Other Fuel (Explain): _________________________ 2. In addition to the main heating fuel you listed in Question 1, do you ever use any of the following to HEAT your home (you can check more than one): Electricity (such as space heaters) Wood (in a fireplace or wood stove) ___________________________ 3. Only answer this question, if you chose NATURAL GAS or ELECTRICITY in Question 1: Have you received a past due notice? YES NO Is your gas or electricity currently shut off / disconnected? YES NO 4. Only answer this question, if you chose PROPANE, FUEL OIL, WOOD, or OTHER in Question 1: Approximately how many days until you run out of fuel completely (enter number of days): Are you currently out of propane, fuel oil, wood or another fuel? YES YES 5. Do you or someone in your household currently receive CalFresh (Food stamps)?

NO 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 information with other offices of the state and federal governments. 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.

____________________________________ Applicant’s Signature

_______________

_______________________________

Date

Witness’ 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.

Cash Assistance being provided under which program  $_______ HEAP WPO weatherized

ECIP WPO

Referral 

SFD – Owner, 1 unit SFD – Rental, 1 unit

HEAP

Fast Track

Home referred for weatherization

Weatherization being billed under which program  Type of Dwelling:

This section is for official use only.

DOE

MFD – Owner, 2 – 4 units Mobile Home – Owner MFD – Rental, 2 – 4 units Mobile Home – Rental MFD – Owner, 5 or more units Energy Cost = $ MFD – Rental, 5 or more units

Agency Defined Priorities:

Medicallly Needy

Frail Elderly

Supplement $______ Total Benefit Referred for ECIP HCS

LIHEAP WX Shelter: # of units _____ Total # of residents: ____

Home already

ECIP HCS Unoccupied MFD: 2 – 4 units Unoccupied MFD: > 5 units

Energy Burden: Severe Financial Hardship

Hard To Reach

% Priority Offsets

THIS FORM MUST BE COMPLETED

Inyo Mono Advocates for Community Action, Inc. (IMACA)

Client Intake Form IMACA CSBG (Rev. 5/2014) Shaded Areas for Official Use Only Agency Location:

BISHOP

Priority Points Intake Date:

Intake Staff:

First Name

Middle Initial

Last Name

Street Address

Sex Unit #

Mailing Address Telephone Number

Service Codes

Telephone Number

Age

Date of Birth (mm/dd/yyyy)

City

County

State

Zip Code

City

County

State

Zip Code

E-mail (optional)

Total number of persons living in The household including yourself

Household Member Information: Include yourself Name of Household Member First, Last Name

Sex

Date of Birth (mm/dd/yy)

Age

Relationship to Applicant

Race/Ethnicity: African American, White, Hispanic or Latino, Asian, Hawaiian/Pacific Islander, Alaskan/Native American, MultiRace

Education: 0-8, 9-10, HS Graduate, 12+ or College Degree

Are you or do you have? Health Insurance, Disabled or Veteran

SELF

1 2 3 4 5 6 7

Household Information Housing (check all that apply to your household) A. B. C. D.

Own Rent Homeless Subsidized or Public Housing

E. F. G. H.

Mobile Home Apartment/Duplex/Condo Single Family Home All Electric Home

E. F. G. H.

Two Adults/no Children Other Teen Parents (under 20) Single Teen Parent (under 20)

Family Type (Check one) A. B. C. D.

Single Parent/Female Single Parent/Male Two Parent Household Single Person

I would like more information about: A. B. C. D. E. F.

Food Assistance G. Head Start/State Preschool Energy Assistance H. Housing Assistance Weatherization I. Garden Assistance Youth or Adult Conservation Corps J. Volunteering with IMACA Holiday Food Baskets/Gifts Program K. Other Child Care Subsidy/Community Connections for Children (Mono County)

Household Income Sources Enter total gross monthly income for all persons living in the household:

No Income TANF SSI/SSP Social Security Pension General Assistance Unemployment Veterans Benefits Interest 1 – Employment 2 – Employment 3 – Employment OTHER

Total Monthly Income

$_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________ $_____________

$____________

Annual Income $________________________ Percentage of Poverty Level _____________%

Applicants Statement: The information on this application will be used to determine and verify my eligibility for assistance with any IMACA program. I also understand that IMACA does not discriminate in the provision of services on the basis of race, color, national origin, disability, age, or sex. I certify that the information I have given is correct and is not provided with the intent to defraud and I am aware that any deliberate falsification of information will be grounds for immediate dismissal from any IMACA program. I herby acknowledge that the information relating to the determination of my eligibility requires verification and/or documentation, and that by my signature I authorize all parties, whether agencies or individuals, to release any and all such information. ________________________________________ ______________ __________________________________ Applicant’s Signature Date Witness’ Signature (if signed with an X) Check box to certify that energy education materials were received.

Department of Community Services and Development Energy Intake Form CSD 43B (05/2014)

IMACA No Income Verification Inyo Mono Advocates for Community Action, Inc. 224 S. Main St, Bishop, CA. 93514 760-873-8557

SURVEY OF INCOME AND EXPENSES You are being asked to complete this form because you (or someone in your household) requested assistance, and it was reported that you have no proof of income. The State of California requires all adults (anyone 18 years and over) living in the household to report all sources of income. If an adult claims to have no proof of income, this form must be completed so we can understand how that person is meeting expenses. Please complete the information below: Name and Address Name: Address:

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

No During the previous month have you been employed part time? No 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, No like yard work, child care, donating blood, etc? During the previous month did you receive any of the following: (circle any that apply) No WORKER’S GOVERNMENT COMP

UNEMPLOYMENT

SPONSORED BENEFITS

CHILD SUPPORT

Do you receive any of the following (circle any that apply) Yes

No

ANNUITY PAYMENT

PENSION

TRIBAL CASINO PAYMENTS

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

No

Yes

No

Yes

No

Yes

No

RENTAL INSURANCE BENEFITS INCOME Put Notary stamp below, if needed (DOE only) or have Executive Director, Sign here

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: EXPENSE

MONTHLY COST

HOW HAS THE EXPENSE BEEN PAID?

$ Rent or Mortgage Utility Bills

IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE: Name:

Phone:

Address:

$

Name:

Phone:

Address:

$ Food

Name:

Phone:

Address:

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

_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ __________________________________________________________________________ Signature: By signing this form, I affirm that I believe these facts are accureate 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

______________________ Date