Neighborhood Centers

Inc.
Housing and Energy Management

2015 Application Request and Checklist

Dear Applicant,

Thank you for your interest in the 2015 Comprehensive Energy Assistance Program (CEAP).
Enclosed you will find an application for utility assistance along with detailed instructions to
help you accurately complete your application.
Please note that a signed, completed application and all required documents must be
submitted in order for your application to be processed in a timely manner. Failure to
submit the required documentation listed below will result in delayed processing or
denial of your application.

Applications can be submitted by Mail or Fax:

Neighborhood Centers Inc. Utility Assistance
3838 Aberdeen Way

Houston, TX 77025

OR

Fax Number: (832) 2955834

Note: Please do not send original documents as they will be not be returned

CEAP 2015 Application CheckList

See attached application instructions page for a detailed explanation of required documentation

CEAP 2015 Application Pages 13: must answer all questions 118

Income Must submit proof of current income for all household members eighteen (18)
years of age and older. Must be consecutive payment periods and within thirty
(30) days of the application date
Current Electric Bill: Provide current bill
For Reliant, Pennywise, and Everything Energy customers Submit a front and
back copy of your electric bill showing meter number and service address
Current Gas Bill: Provide current bill 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: 7135902327 (CEAP) | Fax: 8322955834

Please allow 812 weeks for processing before calling to check your application status

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:
Page 2:
Page 3:

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

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

3.

4.

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 / Workmans 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

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
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

Neighborhood Centers Inc.

Housing and Energy Management

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

Page 3:

Print and Sign name, Date application

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

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

Neighborhood Centers Inc.

Housing and Energy Management
2015 Application for Comprehensive Energy Assistance Program (CEAP)
APPLICANT INFORMATION
Middle Name

1. First Name

Last Name

2. Do you live in Harris County?

Yes No

3. Residential Address

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

City

State

Zip Code

State

Zip Code

4. Mailing Address (if different from above)

City

5. Telephone - (H) (
) __________-_______________
6. Email Address :___________________________________________________________________________________________
Telephone - (Cell) (
) __________-_______________
6A. Would you like to receive status updates via email or text? (PLEASE CHECK ONE) Yes No
Cell Phone Company ______________________________
8. Are you or anyone in the household a veteran?
7. Preferred Language (PLEASE CHECK ONE)
(PLEASE CHECK ONE) Yes No
English Spanish Chinese Vietnamese
HOUSEHOLD MEMBERS INFORMATION
9. List all household members- applicant first
(First Name, Last Name)

9A. Race 9B. Sex 9C. Date of Birth

(M or F)

(MM/DD/YR)

9D. Are you disabled?

9E. Are you receiving? 9F. Are you receiving income?

(Check box below)

(Check box below)

(Check box below)

Yes No

SS SSI

Yes No

Yes No

SS SSI

Yes No

Yes No

SS SSI

Yes No

Yes No

SS SSI

Yes No

Yes No

SS SSI

Yes No

Yes No

SS SSI

Yes No

FOR NEIGHBORHOOD CENTERS INC STAFF USE ONLY:

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

Entered by (Print) _______________________________________________________ (Sign) _____________________________________________________

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Neighborhood Centers Inc.

Housing and Energy Management
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

12. How much is the mortgage or rent?

$__________._______per Month Half Month Two WeeksWeek

(Including Utilities)

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
18A. Type of Bill

18B. Account Holder

(Name on Bill)

Propane/Oil
18C. Utility Provider
(Name of Utility Company)

18E. Meter Number

18D. Account Number

FOR RELIANT, PENNYWISE,

EVERYTHING ENERGY CUSTOMERS
ONLY

Electric
Gas
Propane/Oil
Neighborhood Centers Inc Staff Office Use Only: Case Number 15______________________

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Neighborhood Centers Inc.

Housing and Energy Management

RELEASE OF CUSTOMER INFORMATION

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) _________________________________________________________________
First Name

____________________________________________________________________________
Last Name

Applicant (Signature) ___________________________________________________________________ Date Signed __________________/_________________/__________________________

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

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Neighborhood Centers Inc.

Housing and Energy Management

CEAP 2015 Application Dividers 2 of 4

2. Incomee 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 / Workmans 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*

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

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

Neighborhood Centers Inc.

Housing and Energy Management

DECLARATION OF INCOME STATEMENT

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.
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
List Household Member Name (First and Last Name)

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.)

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)

$________________.________

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.
APPLICANT ONLY

NOTARY PUBLIC ONLY

Applicant Name________________________________________________________________________________________________________________________________

Sworn and subscribed to me on this __________________ day of ____________________, 2015,

DAY
MONTH
in _______________________________County, in the State of Texas.

Applicant Signature__________________________________________________________________________________________

Signature Notary Public _________________________________________________________________

Date Signed ______________/_______________/______________ Case Number 15________________________________

FOR NEIGHBORHOOD CENTERS INC STAFF USE ONLY:

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

Reviewed & Approved By (Manager or Director) _________________________________________________________________________________________________________________________________________
Comments:______________________________________________________________________________________________________________________________________________________________________________________
_

Place Notary Stamp or Seal in this box

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Neighborhood Centers Inc.

Housing and Energy Management

CEAP 2015 Application Dividers 3 of 4

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

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

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

Neighborhood Centers Inc.

Housing and Energy Management

CEAP 2015 Application Dividers 4 of 4

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

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

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

Neighborhood Centers Inc.

Housing and Energy Management

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. Nonpayment 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

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