Liheap Application Energy Intake Form
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32016 LIHEAP APPLICATION INSTRUCTIONS
Please complete the attached application and provide the following information:
ENERGY BILL
HOUSEHOLD INCOME
(current bill, current charges)
(current, one month)
ALL current energy bills must be included
ALL household income for one complete month:
ELECTRICITY BILL:
X
Employment check stubs (current and consecutive)
X
PG&E (any one of the following bills)
CalWIN printout (Cash Aid/GR for current month)
X
Social Security Benefits (award letter, current year)
• Regular blue bill (all pages)
• 48 Hour Notice
• Shut-Off printout
(PG&E office)
• 15 Day Notice
X
SSI – Supplementary Security Income (current year)
GAS BILL:
X
Pension (current, monthly)
X
PG&E (if bundled with electricity)
EDD Unemployment stubs (consecutive for one month)
X
The Gas Company
Disability check stubs (consecutive for one month)
X
Southern California Edison
Child Support printout
PROPANE, WOOD, or OIL invoice:
X
Financial Aid (college student)
Must provide the last invoice or receipt
X
Self-Employed: attach daily journal for one month
Bills that are NOT acceptable:
No Income? Other supporting documents required for
each adult declaring no income.
• Detached/Incomplete bills
(EDD printout – zero earnings verification)
• Closing bill or closed accounts
SOCIAL SECURITY CARD
IDENTIFICATION
Social Security card for ALL adults: 18 and older
California ID or other valid US ID with current legal name
-
Applicant social security card must match ID
- ID for Applicant and for anyone 60 years or over
ADDITIONAL DOCUMENTS MUST BE INCLUDED
(if applicable)
Food Stamps printout from any County Office: (current month) • Must have all names listed on the case
-
Notice of Action not accepted
Low-Income Housing: (current month) • Section 8, HUD, or any other housing assistance
LIHEAP provides one payment per program year for Electricity, Gas, Propane, Wood, or Oil to eligible households.
Walk-In and Mail Address: 1371 Stanislaus Street, Fresno CA 93706
Doors open: 8:00
Monday, Tuesday, Thursday,
Friday. Shut-off bills can be accepted on Wednesday.
and
a.m.
Phone lines open Monday thru Friday 8:30 a.m. – 5:00 p.m. (559) 263-1135
** Walk-In hours and waiting time may vary depending upon the number of applicants signed in to be seen. **
OFFSITE LOCATIONS: (subject to change)
Coalinga: Coalinga Regional Center
311 Coalinga Plaza
First and Second Monday of the month
9:45 a.m. to 3:45 p.m.
Orange Cove: Community Center
1705 Anchor Ave
First and Second Tuesday of the month
9:00 a.m. to 11:30 a.m.
Mendota: Community Center
195 Smoot Ave
First and Second Tuesday of the month
1:00 p.m. to 4:00 p.m.
Reedley: Workforce Connection
1680 Manning Ave
First and Second Tuesday of the month
1:00 p.m. to 4:00 p.m.
West Fresno: Local Conservation Corps
1805 California
First and Second Wednesday of the month
8:30 a.m. to 4:30 p.m.
Selma: Regional Center
3800 McCall Ave
Second and Third Wednesday of the month
8:30 a.m. to 4:00 p.m.
Kerman: County of Fresno E&TA
15180 W. Whitesbridge Ave
First and Second Thursday of the month
9:00 a.m. to 4:00 p.m.
Sanger: Proteus, Inc.
1849 Academy Ave
First and Second Thursday of the month
8:30 a.m. to 4:00 p.m.
You may download a current LIHEAP application from website:
Revised 12/31/15
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