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HEAP Application
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2026-10-05T13:45:05-07:00
HEAP Application
HEAP Application
First Name
(Required)
Last Name
(Required)
Date of Birth
(Required)
Service Address
(Required)
Service City
(Required)
Service County
(Required)
Service State
(Required)
Service ZIP Code
(Required)
Have you lived at this residence during each of the past 12 months?
(Required)
Yes
No
Is your service address the same as mailing address?..
(Required)
Yes
No
Do you own or rent your home
(Required)
Own
Rent
Mailing Address
(Required)
Mailing City
(Required)
Mailing County
(Required)
Mailing State
(Required)
Mailing ZIP Code
(Required)
Home Phone Number
(Required)
Mobile Phone Number
(Required)
Email Address
(Required)
Household Information
Amount of People Living in Household
(Required)
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
Household Income
TANF / CalWORKs
SSI / SSP
SSA/ SSDI
Paycheck(s)
Interest
Pension
Other
Total Monthly Income
(Required)
Applicant (Household Member 1)
First Name
(Required)
Last Name
(Required)
Date of Birth
(Required)
Sex
(Required)
Male
Female
Unknown/Decline to State
Race
(Required)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Multi-Race
Other
Unknown/Decline to State
Hispanic/ Latino/Spanish?
(Required)
Yes
No
Unknow/Decline to State
Have you served or are you an immediate family member of someone who served in the United States military
(Required)
Yes, I have Served
Yes, I am the Spouse, legal partner, parent, or child of a person who served in the United States military
No
Decline to State
I consent to this agency, and CSD, transmitting my name, email address, mailing address, and mobile telephone number to the Department of Veterans Affairs only for the purpose of receiving additional information on veterans benefits for which I or my family member may be eligible. I understand that this consent is valid for 12 months.
(Required)
Yes
No
Amount of Gross Monthly Income (before taxes):
(Required)
Source of Income:
(Required)
Household Member 2
First Name
Last Name
Relationship to Applicant
Date of Birth
Sex
Male
Female
Unknown/Decline to State
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Multi-Race
Other
Unknown/Decline to State
Hispanic/Latino/Spanish
Yes
No
Unknow/Decline to State
Amount of Gross Monthly Income
Source of Income
Household Member 3
First Name
Last Name
Relationship of Applicant
Date of Birth
Sex
Male
Female
Unknown/Decline to State
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Multi-Race
Other
Unknown/Decline to State
Hispanic/Latino/Spanish
Yes
No
Unknow/Decline to State
Amount of Gross Monthly Income
Source of Income
Household Member 4
First Name
Last Name
Relationship to Applicant Member
Date of Birth
Sex
Male
Female
Unknown/Decline to State
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Multi-Race
Other
Unknown/Decline to State
Hispanic/Latino/Spanish
Yes
No
Unknow/Decline to State
Amount of Gross Monthly Income
Source of Income
Household Member 5
First Name
Last Name
Relationship of Applicant
Date of Birth
Sex
Male
Female
Unknown/Decline to State
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Multi-Race
Other
Unknown/Decline to State
Hispanic/Latino/Spanish
Yes
No
Unknow/Decline to State
Amount of Gross Monthly Income
Source of Income
Household Member 6
First Name
Last Name
Relationship of Applicant
Date of Birth
Sex
Male
Female
Unknown/Decline to State
Race
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Multi-Race
Other
Unknown/Decline to State
Hispanic/Latino/Spanish
Yes
No
Unknow/Decline to State
Amount of Gross Monthly Income
Source of Income
Pay Bill Information
Are you or someone in your household CURRENTLY receiving CalFresh (Food Stamps)?
(Required)
Yes
No
To which energy bill (CHOOSE ONLY ONE) do you want the LIHEAP benefit to be applied?
(Required)
Natural Gas
Electricity
Wood
Propane
Fuel Oil
Kerosene
Manufactured log
Pellets
Other Fuel
Company Name
(Required)
Account Number
(Required)
Is your utility service shut-off?
(Required)
Yes
No
Do you have a past due notice?
(Required)
Yes
No
Are your utilities included in rent or submetered?
(Required)
Yes
No
Are your utilities all electric?
(Required)
Yes
No
Is your Natural Gas Company the same as your Electric Company?
(Required)
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)
Energy Information
What is the main fuel used to HEAT your home?
(Required)
Natural Gas
Electricity
Wood
Propane
Fuel Oil
Kerosene
Manufactured log
Pellets
Other Fuel
In addition to your main heating source, do you ever use any of the following to heat your home (you can select more than one):
(Required)
Natural Gas
Electricity
Wood
Propane
Fuel Oil
Kerosene
Manufactured log
Pellets
Other Fuel
N/A
Are you electric bill account holder?
(Required)
Yes
No
Are you natural gas account holder?
(Required)
Yes
No
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