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By clicking on the "Submit" button below, I hereby accept and agree on behalf of myself and my household that the information provided on-line will be used to determine and verify my eligibility for assistance. I also consent to sharing this information with other offices of the state & 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 & 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 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 requested. 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 submitted on-line is true, correct, and that funds received will be used solely for the purpose of paying my energy costs.

AGENCY NAME: Community Services and Development (CSD). UNIT RESPOSIBLE FOR MAINTENANCE: Home Energy Assistance Program. 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. For more information call (866) 675-6623 or visit csd.ca.gov.