2015CEAPApplication-EN.pdf

Neighborhood CentersInc.HousingandEnergyManagement

2015Application Request and Checklist

DearApplicant,

Thankyouforyourinterestinthe2015ComprehensiveEnergyAssistanceProgram(CEAP).Enclosedyouwillfindanapplicationforutilityassistancealongwithdetailedinstructionstohelpyouaccuratelycompleteyourapplication.

Pleasenotethatasigned,completedapplicationandallrequireddocumentsmustbesubmittedinorderforyourapplicationtobeprocessedinatimelymanner.Failuretosubmittherequireddocumentationlistedbelowwillresultindelayedprocessingordenialofyourapplication.

ApplicationscanbesubmittedbyMailorFax:

NeighborhoodCentersInc.–UtilityAssistance3838AberdeenWay OR FaxNumber:(832)295‐5834Houston,TX77025

Note:Pleasedonotsendoriginaldocumentsastheywillbenotbereturned

CEAP2015ApplicationCheck‐ListSeeattachedapplicationinstructionspageforadetailedexplanationofrequireddocumentation

CEAP2015ApplicationPages1‐3: mustanswerallquestions1‐18

Income– Mustsubmitproofofcurrentincomeforallhouseholdmemberseighteen(18)yearsofageandolder.Mustbeconsecutivepaymentperiodsandwithinthirty(30)daysoftheapplicationdate

CurrentElectricBill:Providecurrentbill

ForReliant,Pennywise,andEverythingEnergycustomers‐Submita front andbackcopyofyourelectricbillshowingmeternumberandserviceaddress

CurrentGasBill:Providecurrentbill‐Submitafrontandbackcopyofyourgas bill

showingmeternumberandserviceaddress

NeighborhoodCentersInc.|3838AberdeenWay|Houston,TX77025Telephone:713‐590‐2327(CEAP)|Fax: 832‐295‐5834

Pleaseallow8‐12weeksforprocessingbeforecallingtocheckyourapplicationstatus

Neighborhood Centers Inc. Housing and Energy Management

CEAP 2015 Application Instructions

For your 2015 Application steps 1-4 listed below must be completed

1. CEAP 2015 Application Pages 1-3

Page 1: Answer questions 1 -9 : Answer questions 10 -18 Page 3: Print and Sign name, Date application

2. Income: Must be submitted for all household members eighteen (18) years of age and older

If you receive paycheck stubs, submit the consecutive stubs for the thirty (30) days

prior to the date the application was signed for all household members eighteen (18)

years of age and older. See below income breakdown chart:

If you are paid Weekly = 4 consecutive pay check stubs

If you are paid Bi-Weekly or Semi-Monthly = 2 consecutive pay check stubs

If you are paid Monthly = 1 pay check stub

If you receive Monthly Award Payments, a 2015 Award Letter is required, including:

Social Security (SS) or Supplemental Security Income (SSI)

VA or VA Disability Benefits

Retirement or Pension

Insurance / Workman’s Comp / Annuity Payments

Child Support / Unemployment Benefits / Food Stamp / SNAP or TANF

Child Support or Unemployment Benefits: Provide a Payment Detail

Summary Sheet (date printed must reflect on or after date of signed

application)

Food Stamp / SNAP or TANF: Benefit letter must be within 30 days of

application date. If any other income is listed on the award letter, you

must submit all documented income separately as indicated above

If you are unemployed and not receiving any income, are self-employed, paid in cash, or

receiving family support complete Page 4 of the application:(Declaration of Income

Statement) and have notarized by a Public Notary –Applicant and Notary signature

dates must match

3. Current Electric Bill: Provide entire bill

For Reliant, Pennywise, and Everything Energy customers - You must submit a front and back copy of your electric bill showing meter number and service address

4. Current Gas Bill: Provide entire bill - You must submit a front and back copy of your gas

bill showing meter number and service address

Neighborhood Centers Inc. | 3838 Aberdeen Way | Houston, TX 77025 Telephone: 713-590-2327 (CEAP) | Fax: 832-295-5834


CEAP 2015 Application Dividers 1 of 4

1. CEAP 2015 Application Pages 1-3

Page 1: Answer questions 1-9

Page 2: Answer questions 10-18

: Print and Sign name, Date application

Neighborhood Centers Inc. | 3838 Aberdeen Way | Houston, TX 77025

Telephone: 713-590-2327 (CEAP) | Fax: 832-295-5834


2015 Application for Comprehensive Energy Assistance Program (CEAP)

FOR NEIGHBORHOOD CENTERS INC STAFF USE ONLY:

New Disconnection Re-Apply Resubmitted Case Number 15___________________________Application ID ____________________________

Entered by (Print) _______________________________________________________ (Sign) _____________________________________________________

Page 1 of 5

APPLICANT INFORMATION

1. First Name

Middle Name

Last Name

2. Do you live in Harris County?

Yes No

3. Residential Address

Apt # _______ Unit #______ Trailer #______ Lot#______

City State Zip Code

4. Mailing Address (if different from above)

City State Zip Code

5. Telephone - (H) ( ) __________-_______________ Telephone - (Cell) ( ) __________-_______________ Cell Phone Company ______________________________

6. Email Address :___________________________________________________________________________________________ 6A. Would you like to receive status updates via email or text? (PLEASE CHECK ONE) Yes No

7. Preferred Language (PLEASE CHECK ONE)

English Spanish Chinese Vietnamese

8. Are you or anyone in the household a veteran? (PLEASE CHECK ONE) Yes No

HOUSEHOLD MEMBERS INFORMATION

9. List all household members- applicant first (First Name, Last Name)

9A. Race

9B. Sex (M or F)

9C. Date of Birth (MM/DD/YR)

9D. Are you disabled? (Check box below)

9E. Are you receiving? (Check box below)

9F. Are you receiving income? (Check box below)

Yes No SS SSI Yes No







10. Do you or anyone in the household currently receive? Food Stamps / Lone Star/ Supplemental Nutrition Assistance Program (SNAP) Temporary Assistance for Needy Families (TANF)

11. Is the address listed on this application owned or rented by the applicant? Own Rent (Excluding Utilities) Rent (Including Utilities)

12. How much is the mortgage or rent? $__________._______per Month Half Month Two WeeksWeek

13. Do you live in a? House Apartment Mobile Home Duplex Townhouse Other

Apartment or Landlord name_________________________________________________________________

Telephone Number ( ) _______-____________ Alternate Number ( ) _______-____________

14. Are you interested in the Weatherization Program? Weatherization helps your house to become less leaky, reduce your energy cost, and makes your home more comfortable through the installation of energy saving materials. This progam is free to qualified customers. Yes No 14 A. Are you enrolled in LITE-UP Texas? Yes No

15. How do you cool your home?

A/C Window Unit Central A/C Unit Fans Other None

16. How do you heat your home?

Gas Space Heater Electric Space Heater Central Heat Unit Stove-Oven None 17. Does your name match the name on the utility bills? Yes No (CHECK ONE) If no, explain why (Ex. Deposit too high) _______________________________________________________ __________________________________________________________________________________________________________________________________________________________________________

UTILITY INFORMATION

18. Which utility do you have in your home? Electric Gas Propane/Oil

18A. Type of Bill 18B. Account Holder (Name on Bill)

18C. Utility Provider (Name of Utility Company)

18D. Account Number

18E. Meter Number FOR RELIANT, PENNYWISE,

EVERYTHING ENERGY CUSTOMERS ONLY

Electric Gas Propane/Oil

Page 2 of 5

Neighborhood Centers Inc Staff Office Use Only: Case Number 15______________________

As a CEAP/WAP participant, I do hereby give permission to obtain and release personal information regarding my case to other agencies Neighborhood Centers Inc / companies as deemed necessary to further assist my household in accessing services and to funding sources for reporting purposes. Information requested / released may include, but is not limited to, the following: 1) Services provided to or requested from the household by CEAP / WAP agency and other agencies Neighborhood Centers Inc; 2) Status on utility accounts, payment and consumption histories; 3) Proof of income, residency, and household members; 4) Employment; and 5) Education.

The information provided is true and correct to the best of my knowledge and belief. My household income has been calculated to determine the household yearly income, according to pre-established agency procedures. I understand I may request a hearing to appeal a denial of eligibility, amount of assistance received, or a delay of service delivery. I authorize the Texas Department of Housing and Community Affairs and its contracted agencies Neighborhood Centers Inc to solicit/verify information on my utility

and/or fuel bill, both past and future, to the extent the information is used only to provide data. I hereby authorize the Texas Department of Housing and Community Affairs and Neighborhood Centers Inc to obtain online access to my utility account information

for the purpose of obtaining my 12-month billing history, 12-month payment history, and account balance to be used for the sole purpose of determining my eligibility for benefits in the CEAP/WAP program. I understand that the account information obtained by Neighborhood Centers Inc may contain personal and/or personally-identifying information.

I understand that Neighborhood Centers Inc will never use my information provided here except as needed to process this application. I am aware that I am subject to federal prosecution for providing false or fraudulent information.

My signature indicates I have read the Release of Customer Information, Application Instructions, received a copy of the Customer Acknowledgement

and agree to abide by the terms stated.

Applicant (Print Name) _________________________________________________________________ ____________________________________________________________________________ Applicant (Signature) ___________________________________________________________________ Date Signed __________________/_________________/__________________________

RELEASE OF CUSTOMER INFORMATION

Page 3 of 5

First Name

Last Name

Neighborhood Centers Inc. Office Use Only: Case Number 15_______________________________

arobinson

Typewritten Text

arobinson

Typewritten Text


arobinson

Typewritten Text

2. Income

e –Include proof of income for all household members eighteen (18) years of age and older behind this sheet.

If you receive paycheck stubs, submit the consecutive stubs for the thirty (30) days prior to the date the

application was signed for all household members eighteen (18) years of age and older.

If you receive Monthly Award Payments, a 2015 Award Letter is required, including:

Social Security (SS)* or Supplemental Security Income (SSI)* VA or VA Disability Benefits

Retirement or Pension

Insurance / Workman’s Comp. / Annuity Payments

Child Support or Unemployment Benefits



Provide a Payment Detail Summary Sheet (date printed must reflect on or after date of

signed application)

If you are unemployed and not receiving any income, are self-employed, paid in cash, or receiving family

support, complete Page 4 of the application (Declaration of Income Statement) and have notarized by a

Public Notary -Applicant and Notary signature dates must match.

* Note: As of October 1, 2014 SSA Offices will no longer issue benefit verification letters Go online at www.SSA.Gov/My Account or call 1-800-772-1213*


http://www.ssa.gov/My


This form must be completed and notarized if you answered No to question 9F (for anyone 18 years of age or older) on the application.

I am applying for assistance from Neighborhood Centers Inc and have No documented proof of income due to the reason listed in the table below. Please complete steps 1 – 3 in the chart below for all household members age 18 and over.

I certify that the above information is true and correct to the best of my knowledge. I am aware that I am subject to prosecution for providing false or fraudulent information. I understand that I MUST sign this form in the PRESENCE of a NOTARY PUBLIC. Applicant and Notary Public signature dates MUST match.

1. My household consists of _________ people. The household members listed

(18 years of age and older) in this table have earned the gross income during the previous

30-day period

2. If a household member is 18 years of age or older and has NOT provided proof of income, check one of the reasons below or fill in a reason in “Other Reason.” If proof of income was provided list the type in “Other Reason” (i.e., employer wages, family support, Social Security, Supplemental Security Income, etc.)

List Household Member Name (First and Last Name) Currently enrolled in

school Paid in cash

Unemployed with no Income

Other Reason (please explain)

THIS SECTION IS FOR NEIGHBORHOOD CENTERS INC STAFF USE ONLY:

$________________.________

3. List previous 30-day gross

income

(income received before deductions)

FOR NEIGHBORHOOD CENTERS INC STAFF USE ONLY:

Neighborhood Centers Inc Representative (Print) ________________________________________________________________ (Sign) _______________________________________________________________

Reviewed & Approved By (Manager or Director) _________________________________________________________________________________________________________________________________________

Comments:______________________________________________________________________________________________________________________________________________________________________________________

_ ______________________________________________________________________________________________________________________________________________________________

Page 4 of 5

Applicant Name________________________________________________________________________________________________________________________________

Applicant Signature__________________________________________________________________________________________

Date Signed ______________/_______________/______________ Case Number 15________________________________

APPLICANT ONLY

Sworn and subscribed to me on this __________________ day of ____________________, 2015, in _______________________________County, in the State of Texas.

Signature – Notary Public _________________________________________________________________

NOTARY PUBLIC ONLY

DAY

MONTH

DECLARATION OF INCOME STATEMENT

Place Notary Stamp or Seal in this box



3. Current Electric Bill - Provide entire bill behind this sheet.

For Reliant, Pennywise, and Everything Energy customers

You need to submit the front and back copy of your electric bill showing

meter number and service address


arobinson

Typewritten Text



4. Current Gas Bill - Provide entire bill behind this sheet. You need to submit a front and back copy of your gas bill showing meter number and service address



CUSTOMER ACKNOWLEDGEMENT

PLEASE READ - KEEP THIS PAGE FOR YOUR RECORDS DO NOT SUBMIT THIS PAGE WITH YOUR APPLICATION

I understand the CEAP Program is a federally funded program. Based on available funds, assistance may not be available to all households to receive assistance each year.

If I do receive assistance it is not designed to carry-over to the next calendar year. I am required to apply each year for CEAP Utility Assistance.

I understand CEAP funds are administered by Neighborhood Centers Inc and that CEAP is not an emergency assistance progr am or an entitlement program. Application processing period

can take up to 12 weeks following application intake. Applications are processed by priority and my application does not guar antee assistance. I understand that my household must meet

the 2015 Federal Income Guidelines and live in Harris County.

I understand that if I do not submit all the REQUIRED documentation as listed on the application request instruction letter there will be a delay in processing my application. I understand that Neighborhood Centers Inc will not secure any pledge(s) or make utility payments until the application process has been completed and that CEAP assistance is subject to

availability of funds. During the application and eligibility process. I am fully responsible for my bill before, during, and after the application and eligibility determination process. Non- payment of a utility bill may result in interruption of services.

I understand that Neighborhood Centers Inc will not pay any late fees, deposits, reconnect charges and that I am responsible f or making payments for those fees and charges to my utility provider.

If my application is approved, I will receive a Notice of Eligibility (NOE) indicating the programs I qualify for, as well as benefit a mount(s). If my application is denied, I will receive a Notice of Denial (NOD) with the reasons indicated. I will also be provided with infor mation on the appeal process. I understand that all Disconnection Notices will be processed within 48 hours after the application is determined to be eligible. I understand that the Utility Assistance Program provides assistance for electric or gas utility bills only (not water, rent/mortgage, cab le or telephone). I understand that by requesting to receive status updates on my application via email and/or text, all messaging fees are my re sponsibility. I understand that I am responsible for notifying Neighborhood Centers Inc of changes that could affect payment to my account including but not limited to:

Change of Account Number Change of Utility Provider Change of Address, Telephone, or Email

PLEASE READ - KEEP THIS PAGE FOR YOUR RECORDS - DO NOT SUBMIT THIS PAGE WITH YOUR APPLICATION

Neighborhood Centers Inc. - CEAP 3838 Aberdeen Way Houston, TX 77025

Telephone: 713-590-2327 (CEAP) | Fax: 832-295-5834

Pa e 5 of 5

2015CEAPApplication-EN.pdf

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