If you have any questions or concerns, please do not hesitate to call us at (209) 723-3201
State of California Department of Community Services and Development Energy Intake Form | CSD 43 (07/2024)
Name*
First
Middle
Last
Date of Birth*
MM slash DD slash YYYY
Service Address - Address where you live (this cannot be a P.O. Box)*
How long have you lived at this address?*
Is your service address the same as mailing address?* Do you own or rent your home?* Mailing Address*
Social Security Number (SSN)*
Telephone Number*
Email Address:*
People Living In Household* Enter the total number of people living in the household, including yourself
Income* Enter the total number of people who receive income
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
First
Last
Address*
Section 1: Do you have sources of income you forgot to report? During the previous month have you been employed part time?* 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, like yard work, child care, donating blood, etc?* 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:* During the previous month did you receive any of the following: (select any that apply) Do you receive any of the following: (select any that apply) Section 2: Are you spending your savings or borrowing
money to cover monthly expenses? 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: Rent or Mortgage MONTHLY COST*
HOW HAS THE EXPENSE BEEN PAID?
IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:
Name
First
Last
Phone
Address
Utility Bills MONTHLY COST*
HOW HAS THE EXPENSE BEEN PAID?
IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:
Name
First
Last
Phone
Address
Food MONTHLY COST*
HOW HAS THE EXPENSE BEEN PAID?
IF SOMEONE ELSE PAYS FOR YOU, PLEASE COMPLETE:
Name
First
Last
Phone
Address
Section 4: If none of the above applies to you, please explain how your monthly expenses were paid:
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:*
First
Last
Date
MM slash DD slash YYYY
Demographics Enter the total number of people living in the household who are:Ages 0-2 years
Ages 3-5 years
Ages 6-18 years
Ages 19-59 years
Ages 60 and older
Disabled
Native American
Seasonal or Migrant Farmworker
Enter the total gross all TANF / CalWorks
SSI / SSP
SSA / SSDI
Paycheck(s)
Interest
Pension
Other
Total Monthly Income
HOUSEHOLD MEMBERS* Choose 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
SELECT THE NUMBER HOUSEHOLD MEMBERS, THEN FILL OUT THE INFORMATION FOR ALL HOUSEHOLD MEMBERS.
Applicant (Household Member 1) Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 2 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 3 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 4 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 5 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 6 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 7 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 8 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 9 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 10 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 11 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 12 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 13 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 14 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 15 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 16 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 17 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Member 18 Name*
First
Last
Relation to Applicant*
Date of Birth*
MM slash DD slash YYYY
Amount of Gross Monthly Income*
(Before Taxes and Deductions)
Source of Income*
Household Total Monthly Gross Income
Are you or someone in your houshold CURRENTLY receiving CalFresh (Food Stamps)?* PAY BILL* To which energy bill (CHOOSE ONLY ONE) do you want the LIHEAP benefit to be applied? (Attach complete copy of most recent bill or receipt)
Enter the energy company and account number: Company Name:*
Account #:*
Is your utility service shut-off?* Do you have a past due notice?* Are your utilities included in rent or submetered* Are your utilities all electric?* Is your Natural Gas Company the same as your Electric Company?* WOOD, PROPANE or FUEL OIL SERVICE (WPO) Are you currently out of fuel?* (Wood, Propane, Oil, Kerosene, Other Fuels)
List the approximate number of days until you run out of fuel* (Wood, Propane, Oil, Kerosene, Other Fuels)
ENERGY INFORMATION
The questions below are MANDATORY . Please check all energy sources used to heat your home.
A copy of ALL recent energy bills and/or receipts for any home energy cost must be provided.
NOTE: A copy of an electric bill must be included even if you do not use electricity to heat your home. What is the main fuel used to HEAT your home?* One main heating source MUST be checked.
Are you the account holder:
Electric Bill* Natural Gas Bill* The information on this application will be used to determine and verify my eligibility for assistance. By signing below, I give my consent (permission) to CSD, its contractors, consultants, other federal or state agencies (CSD Partners) and to my utility company and its contractors, to share information about my household's utility account, energy usage and/or other information needed to provide services and benefits to me as described at the end of the form. My consent shall be effective for the period beginning 24 months prior to, and continuing for 36 months after, the date signed below. 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. APPLICANTS SIGNATURE*
First
Last
Typing your name here will count as your signature.
Date*
MM slash DD slash YYYY
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. LIHEAP Energy Conservation Education Participant:*
First Name
Middle Initial
Last Name
Address
Telephone No.
To assist in reducing energy consumption and energy costs, the Community Action Agency has provided Energy Conservation Education and Informational Literature to me on the following topics: Weatherization Referral* Cooling/Summer Tips* Heating/Winter Tips* Water Heaters* Cooking* Appliances* Lighting* Miscellaneous* Signature of Participant*
First
Last
Date
MM slash DD slash YYYY
Hidden
Signature of Intake Worker
First
Last
Hidden
Date
MM slash DD slash YYYY
Merced County Community Action Agency
Energy/Weatherization Department
1235 W. Main St. – P.O. Box 2085 – Merced, CA
LIHEAP APPLICANT FINANCIAL MANAGEMENT COUNSELING Participant:*
First Name
Middle Initial
Last Name
Address*
Phone #*
Name of Program in which assistance is being requested:*
1. Monthly Household Income: a. Source of Income:*
b. Gross Monthly Income:*
c. Net Monthly Income:*
2. Monthly financial obligations - (monthly bills paid by applicant) a. Rent/Mortgage payment:*
b. Food/Household Exp:*
c. Credit Card payment:*
d. TV/Cable payment:*
e. Telephone payment:*
f. Water/Garbage payment:*
g. Utility payment:* (PG & E, MID, TID, Propane, etc.)
h. Transportation Exp.:*
i. Car payment:*
j. Other monthly payments (be Specific) Name
Amount
Name
Amount
Name
Amount
GRAND TOTAL:*
Participants in CAA’s direct assistance programs are required to present documented proof of monthly income. 3. Possible available cash after all monthly obligations are paid:*
4. Problems – (why does applicant need financial assistance from CAA?)*
Utility Company Name:*
Participant’s Signature*
First
Last
Date
MM slash DD slash YYYY
Hidden
Intake Worker’s Signature
First
Last
Hidden
Date
MM slash DD slash YYYY
This project, program or service is funded in whole or in part by the California Dept. of Community Services and Development. CLIENT TRACKING FORM SSN#*
Name
First Name
Last Name
Date of Birth*
MM slash DD slash YYYY
Age*
Address*
Telephone*
Household / Applicant Information Gender* Disabled* Food Stamps* Veteran* Health Insurance* Ethnicity* Education* Farmers Family Type* Housing* Income Sources:* Other Income Source*
Income Amount:*
Household Members Information Household Member 1 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 2 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 3 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 4 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 5 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 6 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 7 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 8 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 9 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 10 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 11 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 12 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 13 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 14 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 15 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 16 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 17 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* Household Member 18 SSN#*
Name*
First
Last
Date of Birth*
MM slash DD slash YYYY
Age*
Gender* Disabled* Ethnicity* Education* Health Insurance* Veteran* I certify that this statement is true and correct to the best of my knowledge, and authorize the release of any
and all information necessary for verification purposes.
Yo cerifico que esta declaracion es cierta y correcta, y autorizo el uso de esta informacion para proposito de
verificasion.
Signature of Client*
First
Last
Typing your name here will qualify as your signature.
Date*
MM slash DD slash YYYY
Have you received services from any of the programs listed below in the last 120 days?* Notes/Comments:
Completed Application Form: (Energy Intake Form CSD 43)
Current Energy Bill(s):
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.
Adult Occupants:
Current government-issued photo ID and Social Security Card for all occupants 18 years or older.
Child Occupants:
Social Security Cards, birth certificates, or immunization records for all occupants younger than 18 years.
Applications from Owners: Provide a copy of the deed, title, or property tax papers, as proof of ownership.
Applications from Renters: Provide the owner's name, mailing address, and telephone number- MCCAA must contact the owner to complete some mandatory paperwork before we will be able to continue.
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Name
First
Last
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