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家庭能源补助计划
(HEAP)
申请资料
帮助Alameda县居民支付
太平洋煤电公司和Alameda县供电局电费
请将填妥的表格以及所需的有关文件寄到:
Spectrum Community Services
Attn: 吴先生 , 510-881-0300 Ext. 226
HEAP Program
P. O. Box 4317
Hayward, CA 94540
请不要涂改你填写的表格
请提供以下文件的复印件
1) 你的申请表
2) 完整的太平洋煤电公司和Alameda县供电局的账单
要30天之内的，请包括48小时内的通知(如果可能提供的话)
3) 收入证明
工资单 - 支票存根
月薪，一期工资单；半月薪，两期工资单；周薪，四期工
资单
SSI/SSA—2017 政府通知书，银行月结单， 银行存折,
SSI/SSA 支票复印件
EDD—过去4周的支票存根
GA (General Assistance)— 过去30天之内受理的Cal-
Learn, CalWorks, Food Stamp确认书或相关文件
贷款或者临时的资助—如果你得到朋友或者亲戚的资助,
(如果是每月的，请提供写有数额和日期的签名信)
自雇人员—我们需要完整的签了名的Schedule
C报税表,或是 过去30天的收支总帐或收款凭单。
还有…
残障的证明
SSI/SSA—2017年确认书
医生的证明信
EDD 发出的残疾证明信
DMV 发出的残疾卡
家庭成员是60岁以上的:
请提供以下任何的复印件：加州驾驶证，身份证，美国护照，保险
卡或者出生证明。
5岁或以下的儿童:
请提供以下任何的复印件：出生证明，疫苗注射记录，保险卡或者
写有出生日期的医疗记录。
如何填写
家庭能源补助计划(HEAP) 申请表
申请书样板
请勿填写.
1) & 2) 请填写你的名和姓
3)请填写你的通讯地址，包括你的公寓号码
4) 请填写你的出生日期
5)你所提供的地址是否与太平洋煤电公司或Alameda县供电局账单上的地址一致?
是/不是
6) 请填写你的社会安全卡号
7)请填写你的电话号码
8) 包含你本人在内有多少家庭成员？请按年龄组别详细列出。例如：有多少个家庭成员年龄是在19岁-59岁之间? 有多少个家庭成员年龄是在60岁或以上? 请包含你本人
9) 请在这栏填写总收入。同时请列明金额的收入类型。SSA, SSI, 工资粮单或者是其它类型的收入
10) 请填写你的姓名，出生日期，每月收入和收入来源，同时请包含每一个与你同住有收入的家庭成员的姓名，关系，出生日期，每月收入及来源。请填写家庭每月总收入 (税前)
11) 你或者其他人目前是否接受Cal/Fresh(粮食券)
P.O. Box 4317 Hayward, CA 94540 (510) 881-0300 www.SpectrumCS.org
5)
6) 7)
8) 9)
10)
11)
2) 4)
3)
1)
Sam
ple P
age
Do n
ot use.
12)请在相应的方框打勾以及填写能源供应公司名称和账户号码
13) 你家取暖的主要的燃料是什么? 请在方框打勾
14) 除了主要的取暖方式，你是否曾经使用如下任何一种方式取暖(可选择多于一项)
14) 除了主要的取暖方式，你是否曾经使用如下任何一种方式取暖(可选择多于一项)
15) 你家所有电器都是使用电力吗？
你的电力供应停止过吗?
你有没有收到过期缴费的通知单?
16) 你家的天然气公司是否与电力公司一致?
你有被断掉电力供应吗?
你有没有收到过期的通知单?
17)如果你有使用木材，丙烷，燃油服务(WPO)，请列出
18)你家的煤电费包含在租金里或是分电表?
是/不是
19) 请签名以及填写日期。
P.O. Box 4317 Hayward, CA 94540 (510) 881-0300 www.SpectrumCS.org
19)
12)
15)
16)
13)
17)
14)
18)
Sam
ple P
age
Do n
ot use.
申请人收到资讯教育确认书
1) 请填写名字
2) 请填写你的通讯地址，包
括城市名以及邮区号码
3) 请在相应的格子打勾。这
表示你收到关于能源教育
和预算建议
4) 请签名
5) 请填写日期
收入和支出证明
如果你或你家庭中有18
岁或以上的家庭成员没
有收入请填写这部分
1)
2)
3)
4) 5)
P.O. Box 4317 Hayward, CA 94540 (510) 881-0300 www.SpectrumCS.org
Sam
ple P
age
Do n
ot use.
家庭能源补助计划(HEAP) 合资格申请人同意书
联邦政府的HEAP(家庭能源补助计划)要求州政府帮助收入低、能源费用高的
符合收入限额资格的家庭。家庭中有老年人、残障者和五岁或以下儿童的优
先得到帮助。以下图表为该补助计划的收入限额：
2017 每月总收入限额表 家庭人数 每月总收入
1 $2,091.92
2 $2,735.58
3 $3,379.25
4 $4,022.92
5 $4,666.58
6 $5,310.25
请明白HEAP并非一个应得权利的计划。Spectrum同时提供家庭节能改造服务来帮助家庭减低煤电费开支。建议所有申请人与他们的能源供应机构协商付
款计划。
我明白和阅读以上内容。
__________________________ ____________________
签名 日期
查询请致电: (510) 881-0300, 内线: 226
First name Middle Initial Last Name Date of Birth MM/DD/YY
Mailing Address Unit Number
Mailing City Mailing County Mailing State Mailing Zip Code
SERVICE ADDRESS – Address where applicant lives (this cannot be a P.O. Box) Is your service address the same as mailing address?............................................................................................................ ☐ Yes ☐ No Have you lived at this residence during each of the past 12 months…………………………………………………………………………………. ☐ Yes ☐ No Service Address Unit Number
Service City Service County Service State Service Zip Code
Social Security Number (SSN): Telephone Number ( ) ☐Message Only?
E-mail Address (Optional):
HOUSEHOLD MEMBERS (Optional) FULL NAME: Full name is First Name, Last Name. RELATIONSHIP TO THE APPLICANT: For example: husband, daughter, friend, aunt, grandfather, etc. DATE OF BIRTH: List the date of birth of each household member. AMOUNT OF MONTHLY GROSS INCOME: “gross” income means the amount of money received before taxes or anything else is taken out. If you have more than 8 people in your household, you can write the information on a separate piece of paper.
First Name Last Name Relation to Applicant
Date of Birth MM/DD/YY
Amount of Monthly Income Source of Income
Self
Household Total Monthly Gross Income $ Are you or someone in your household CURRENTLY receiving CalFresh (Food Stamps)? ☐ Yes ☐ No
Department of Community Services and Development Official Use Only: Energy Intake Form Priority Points CSD 43 (11/2015) A.C.C.Agency: Intake Initials: Intake Date: Eligibility Cert Date
Job Control Code
PEOPLE LIVING IN HOUSEHOLD Enter the total number
of people living in the household, including the applicant
INCOME
Enter the number of household members who receive income
Demographics - Enter the number of people who are: Enter total gross monthly income for all people living in the household:
Ages 0 – 2 Years TANF / CalWorks $
Ages 3 - 5 years SSI / SSP $
Ages 6 - 18 years SSA / SSDI $
Ages 19 - 59 Paycheck(s) $
Ages 60 and older Interest $
Disabled Pension $
Native American Other $
Seasonal or Migrant Farmworker Total Income $
Spectrum CS
To which energy bill do you want the LIHEAP benefit to be applied? (Attach copy of most recent bill or receipt)
☐ Natural Gas ☐ Electricity ☐ Wood ☐ Propane ☐ Fuel Oil ☐ Kerosene ☐ Other FuelList energy company and account number: Company Name: _____________________ Account #: ____________________________What is the main fuel used to HEAT your home? A main heating source MUST be checked. (Attach copy of most recent bill or receipt)
☐ Natural Gas ☐ Electricity ☐ Wood ☐ Propane ☐ Fuel Oil ☐ Kerosene ☐ Other FuelIn addition to your main heating source, do you ever use any of the following to heat your home (you can select more than one): (Attach copy of most recent bill or receipt)
☐ Natural Gas ☐ Electricity ☐ Wood ☐ Propane ☐ Fuel Oil ☐ Kerosene ☐ Other Fuel ☐ N/AEnergy Bill Information Check all that apply for each type of energy source for any home energy costs. NOTE: The questions below are MANDATORY and require a response. Required: Attach copies of all most recent energy bills and/or receipts. A copy of an electric bill must be included.
ELECTRIC SERVICE
Are your utilities all electric? ☐ Yes ☐ No _ __ __Is your electricity shut-off?☐ Yes ☐ No Do you have a past due notice?☐ Yes ☐ No
NATURAL GAS SERVICE
Is your Natural Gas Company the same as your electric Company? ☐ Yes ☐ No Is your Natural Gas shut-off?☐ Yes ☐ No Do you have a past due notice?☐ Yes ☐ No
WOOD, PROPANE or FUEL OIL SERVICE (WPO)
Are you currently out of fuel? (Wood, Propane, Oil, Kerosene, Other Fuels) ☐ Yes ☐ No ☐ N/A
List the approximate number of days until you run out of fuel (Wood, Propane, Oil, Kerosene, Other Fuels).
Number of Days: _____________ ☐ N/A
Are your utilities included in rent or submetered? ☐ Yes ☐ NoThe 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 my account information with the Department of Community Services and Development (CSD), its designated subcontractors, and other offices of the state and federal governments for the purpose of providing services to me and to coordinate, improve and reduce the costs of services under these programs. I further authorize my utility company(ies) to provide my energy consumption data to CSD to the extent necessary for CSD to comply with the program reporting requirements of the federal government. I understand that this consent shall remain in effect for three years from the date signed unless otherwise revoked by me in writing. 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.
X * * * APPLICANT’S SIGNATURE * * * Today’s Date Witness’s 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. THIS SECTION IS FOR OFFICIAL USE ONLY. Utility Assistance being provided under which program ☐ HEAP ☐ Fast Track ☐ HEAP WPO ☐ ECIP WPO Supplement $________________ Total Benefit $_______________ ☐ Home referred for WX ☐ Home already weatherizedEnergy Services Restored after disconnection: ☐ Yes ☐ No Disconnection of Energy Services prevented: ☐ Yes ☐ No Type of Dwelling: ☐ MFD – Owner, 2 - 4 units ☐ Mobile Home – Owner ☐ Shelter: # of units _______ ☐ Unoccupied MFD: 2 – 4 units☐ SFD – Owner, 1 unit ☐ MFD – Rental, 2 - 4 units ☐ Mobile Home - Rental Total # of residents: _____ ☐ Unoccupied MFD: > 5 units ☐ SFD – Rental, 1 unit ☐ MFD – Owner, 5 or more units Total Energy Cost: Energy Burden:
☐ MFD – Rental, 5 or more units $ %Agency Defined Priorities: ☐ Medically Needy ☐ Frail Elderly ☐ Severe Financial Hardship ☐ Hard to Reach ☐ Priority Offsets ☐ N/A
Put Notary stamp below, if needed (DOE only) or have Executive Director Sign here
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 and Address
Name:
Address:
Section 3: Please tell us how you paid these monthly expenses during the previous months:
EXPENSE MONTHLY COST HOW HAS THE EXPENSE BEEN PAID? IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:
Rent or Mortgage $
Name: Phone: Address:
Utility Bills $
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 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 Date
Section 1: Do you have sources of income you forgot to report? YES NO During the previous month have you been employed part time? YES NO During the previous month have you been self-employed?
YES NO 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?
YES NO 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:
YES NO During the previous month did you receive any of the following: (circle any that apply)
WORKER’S COMP UNEMPLOYMENT GOVERNMENT SPONSORED BENEFITS CHILD SUPPORT
YES NO Do you receive any of the following (circle any that apply) ANNUITY PAYMENT PENSION TRIBAL CASINO PAYMENTS RENTAL INCOME INSURANCE BENEFITS
Section 2: Are you spending your savings or borrowing money to cover monthly expenses?
YES NO Are you using savings or a home equity loan? How much? ____________________________
YES NO Are you using some other asset? How much?____________________________
YES NO Are you borrowing from credit cards? How much?____________________________
YES NO Are you borrowing from some other source? How much?____________________________
Put Notary stamp below, if needed (DOE only) or have Executive Director Sign here
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 and Address
Name:
Address:
Section 3: Please tell us how you paid these monthly expenses during the previous months:
EXPENSE MONTHLY COST HOW HAS THE EXPENSE BEEN PAID? IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:
Rent or Mortgage $
Name: Phone: Address:
Utility Bills $
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 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 Date
Section 1: Do you have sources of income you forgot to report? YES NO During the previous month have you been employed part time? YES NO During the previous month have you been self-employed?
YES NO 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?
YES NO 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:
YES NO During the previous month did you receive any of the following: (circle any that apply)
WORKER’S COMP UNEMPLOYMENT GOVERNMENT SPONSORED BENEFITS CHILD SUPPORT
YES NO Do you receive any of the following (circle any that apply) ANNUITY PAYMENT PENSION TRIBAL CASINO PAYMENTS RENTAL INCOME INSURANCE BENEFITS
Section 2: Are you spending your savings or borrowing money to cover monthly expenses?
YES NO Are you using savings or a home equity loan? How much? ____________________________
YES NO Are you using some other asset? How much?____________________________
YES NO Are you borrowing from credit cards? How much?____________________________
YES NO Are you borrowing from some other source? How much?____________________________
每月預算
每月总收入(税前) $
每月净收入(税后) $
每月基本的开支
房屋租金/贷款 $
食物 $
每月公用事务费开支
水费 $
电话费 $
垃圾费
太平洋煤电公司 /Alameda 供电局账单
煤气费 $
电费 $
总开支 $
(每月净收入)减去( 总开
支)
$
你的合计:
每月基本的开支
+
每月公用事务费开支
+
煤电费
每月净收入减去总开支
为什么要做预算?
预算是一个开支计划, 让你清楚知道你的钱用在何处和什么对你最重要。 这里有一个
月的预算表，让你看看自己如何开支。请填写以下的预算资料。
请留意，我們]做了以下表格样式帮助你知道你的錢用在哪些地方。
Lead-Safe Energy Mold/Moisture Budget Counseling Radon
Date Time Date Time Date Time
Lead-Safe Energy Mold/Moisture Budget Counseling Radon
Date mailed
Self-Certification Option
If the information was delivered but a signature was not obtainable, you may check the appropriate box below.
I certify that I attempted to deliver the following educational information to the dwelling listed above:
Radon Education - A copy of the pamphlet, A Citizen's Guide to Radon , informing me of the potential
risk of radon and how to lower the radon level in my dwelling unit.
State of California
DEPARTMENT OF COMMUNITY SERVICES AND DEVELOPMENT
CSD 321 (Rev. 12/05/11)
CLIENT EDUCATION CONFIRMATION OF RECEIPT
Attempted delivery dates and times
Signature (Agency Representative)
Signature (Agency Representative) Print name
Mailing Option:
Refusal to Sign — I certify that I have made a good faith effort to deliver the information to the dwelling
unit listed above at the date and time indicated and that the occupant refused to sign the confirmation of
receipt. I further certify that I have left a copy of the information at the unit with the occupant.
Unavailable for Signature — I certify that I have made a good faith effort to deliver the information to
the dwelling unit listed above and that the occupant was unavailable to sign the confirmation of receipt. I
further certify that I have left a copy of the information at the unit by sliding it under the door.
I certify that I have mailed the following educational information to the dwelling listed above (attach copy of
Certificate of Mailing for lead-safe education only):
Print name
Energy Education – Information regarding changes I can make in order to reduce the energy
consumption of my household.
Budget Counseling - Information regarding personal financial management.
I have received the following information:
DateSignature of Recipient
Mold and Moisture Education - A copy of the pamphlet, A Brief Guide to Mold and Moisture In Your
Home , informing me of how to clean up residential mold problems and how to prevent mold growth.
Confirmation of Receipt
Lead-Safe Education – A copy of the pamphlet, Renovate Right: Important Lead Hazard Information
for Families, Child Care Providers, and Schools , informing me of the potential risk of the lead hazard
exposure from weatherization/renovation activity to be performed in my dwelling unit.
Name of Occupant Age of Dwelling
Address of Dwelling
能源小提示
采取这些节能措施
● 选择节能Energy Star®型号的冰箱、洗衣机、干衣机和洗碗机来取代
旧机。
● 买一个符合你需要的热水器。
● 在天花板上做保温隔热装置。
● 填补窗户、门和任何有漏气的地方。不要填补热水器和暖气炉周围的
排气管。
● 在门和窗户的周围加密封条。
● 用管道胶布包裹冷暖风管。
● 使用节能灯泡。
暖气：
➔ 在白天可以把暖气的温度设在华氏68度或以下。
➔ 如果身体条件允许可以在晚间把温度调到55度或者关掉。
➔ 请专业的工程人员检查和维护暖气机。
➔ 每月清洁或更换暖气机的过滤网。
➔ 检查暖气机的排气管、散热器和感应器。
➔ 穿着毛衣或多层衣物以保持身体的热量。
➔ 白天打开窗帘让太阳温暖你的房子，晚上则关上它们帮助房子保温。
➔ 关上不用的房间的门和里面的出风口。
➔ 不使用时将火炉的风门关紧闭。
➔ 关上门和窗户。
➔ 用双层玻璃的窗取代旧的窗户
你可以这样做:
你可以这样做：
：：::::?::
你可以怎样做：
空调：
➔ 在夏天，可以把温度感应器设在78度或者关闭。
➔ 优先选用电风扇和自然通风。
➔ 穿着凉快的衣服。
➔ 夏天，在白天关上窗帘以防止热气进入房屋。
水：
➔ 购买一个符合你需要的Energy Star®节能热水器。
➔ 把热水器的温度调低到华氏120度。
➔ 为热水器做保温装置。
➔ 安装节能淋浴花洒头。
➔ 缩短洗澡的时间。
➔ 修理好漏水的水龙头和安装节能的喷气型水龙头。
➔ 将洗碗机装满才使用，并且使用风干模式来干碗碟。
➔ 洗衣服时，尽量装满洗衣桶并且用冷水进行清洗。
➔ 天气好时，把衣服拿到外面晒干。
其它节能的方法：
➔ 关掉电灯。
➔ 关掉那些不使用的房间的门和出风口。
➔ 拔掉电源头和充电器。
➔ 不要在睡觉时或不在房间的时候开着小型的暖气机。暖气机至少放在
床单、窗帘、家具和其它易燃物品的三尺之外。
千万不要用厨房的炉头、烤炉或烧烤炉来加热你的房子
请填写你的名字: __________________________________
居住城市:_________________________________________
你是如何得知家庭能源补助计划 (HEAP)的?
例如:
朋友和家人
能源公司
宣传单张
有关机构
如果是有关机构介绍给你的，请写出该机构的名字
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
谢谢你的反馈
