APLICANTES DEL PROGRAMA DE ASSISTENCIA DE LA SEQUIA DE AGUA (DWAP)!

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1 APLICANTES DEL PROGRAMA DE ASSISTENCIA DE LA SEQUIA DE AGUA (DWAP)! Por favor este consciente que este programa NO es un programa de emergencia y tomara de 2 a 3 meses (de la fecha que su aplicación es procesada) para que el crédito aparezca en su cuenta de Agua. Es su responsabilidad continuar haciendo pagos en su cuenta de utilidades. Ya que haiga sido procesada su aplicación, usted recibirá una carta avisándole que su aplicación ha sido procesada y la cantidad por la cual es elegible a recibir. Aviso: No todos los solicitantes serán elegibles para asistencia. Aplicaciones deben cumplir con los criterios del Plan de Prioridad. Si su aplicación no puede ser procesada por alguna razón, le enviaremos una carta con detalles. CRITERIOS PARA EL PROGRAMA DE ASISTENCIA DE LA SEQUIA DE AGUA Los servicios están disponibles para los hogares de bajo recursos que residen en el condado de Madera, y que cumplen con los requisitos del programa. 4. Factura de servicios Públicos de agua; debe proporcionar copias de la factura (s) de agua y / o notificación de apague para el mes actual, además las facturas de agua de hasta dos (2) meses anteriores si solicitan asistencia con saldos atrasados. 5. Provee una COPIA de la factura más reciente de PG&E y su etiqueta de Gas Propano con fechas no mayor de 6 semanas. 6. NO UTILICE LIQUIDO CORRECTIVO BLANCO. TODA LA INFORMACION ES CONFIDENCIAL Cuentas de 48 horas y Desconectadas son con cita solamente Aplicaciones serán aceptadas hasta que se agoten los fondos Preguntas, llame al El solicitante debe vivir en el domicilio que aparece en su cuenta y ser mayor de 18 años de edad. Debido a cambios en el programa del 2014 acerca de prioridades, NO todos serán ayudados. Debido a los recortes presupuestarios, CAPMC ya no es capaz de hacer Copias de la información requerida. Regrese/Traiga FOTO COPIAS de lo siguiente 1. Regrese el paquete de aplicación completado y firmado 2. Una COPIA de su tarjeta de Seguro Social 3. Provee todas las pruebas de ingresos totales del hogar para las seis semanas anteriores de la fecha que someta la aplicación. Ejemplos: COPIAS de talones de cheques, cartas de verificación para SSI/SSP/SSA, talones de beneficios de desempleo, asistencia general, pensiones y/o pasaporte a servicios del mes actual para TODOS los miembros del hogar. ATTENTION DROUGHT WATER ASSISTANCE PROGRAM (DWAP) APPLICANTS! Please be aware that this is NOT an emergency assistance program and it will take anywhere from 2 to 3 months (from the date your application is processed) for the credit to show up on your WATER bill. Note: Not all applicants are eligible for assistance. Applications must meet the Priority Plan criteria. If your application cannot be processed, you will receive a letter in the mail with details. It is your responsibility to continue making payments on your water bill.

2 Community Action Partnership of Madera County Drought Water Assistance Program (DWAP) 1225 Gill Avenue Madera, CA Once your application has been processed, you will receive a letter in the mail letting you know that your application has been processed and the amount that you are eligible to receive. DROUGHT WATER ASSISTANCE PROGRAM CRITERIA Services are available to income eligible households residing in Madera County and who meet program guidelines. Applicant must live at the address which appears on the bill and be at least 18 years of age. Due to changes in the 2014 program year in regards to prioritization, NOT everyone who applies will be assisted. Due to budget cuts, CAPMC is no longer able to make photo copies of the required information. Mail/bring PHOTOCOPIES of the following 1. Return completed and signed Application Packet 2. Provide COPY of the APPLICANT S social security card 3. Provide ALL proof of total household income for the previous six weeks of the date of submission. For Example: COPIES of check stubs, award letters for SSI/SSP/SSA, unemployment check stubs, general relief letters, pensions, and or passport to services of TANF for the month of application for all household members 4. Provide a copy of a COMPLETE PG&E AND PROPANE delivery tag (not older than 6 weeks) 5. Water Utility Bill; must provide copies of water bill(s) and /or shut off notice for the current month, plus water bills for up to two (2) previous months if requesting assistance with past due balances. 6. DO NOT USE WHITE-OUT ALL INFORMATION PROVIDED IS CONFIDENTIAL Applications will be accepted until funds have been exhausted. Questions, call

3 Department of Community Services and Development Drought Water Assistance Program Pilot Intake Form CSD 818 (04/2014) Agency: CAP of Madera Intake Initials: Intake Date: Eligibility Cert Date: First Name Middle Initial Last Name Mailing Address Check if same as service address Unit Number Mailing City Mailing County Mailing State Mailing ZIP Code Service Address (Do not use P.O. Box) Unit Number Service City Service County Service State Service ZIP Code CA Social Security Number (SSN): Telephone Number: ( ) Message Only? PEOPLE LIVING IN HOUSEHOLD Enter the total number of people living in the household, including the applicant --> Enter the number of people who are: Ages 0-5 Ages 6-11 Ages Ages Ages Ages Ages Ages 70 + Disabled Seasonal Farmworker Migrant Farmworker * Questions 1-4 (below) are MANDATORY fields. INCOME TANF SSI/SSP Social Security Pension Gen. Assistance Unemployment Employment Other Enter the total number of household members who receive income --> Enter total gross monthly income for all people living in the household: TOTAL INCOME PAYMENT DETAILS What is the total cost of the water bill? Name of water utility company: Account Number: Name of customer on the water bill: Check here if your water bill is included in your rent. 1. How were you directly impacted by the drought? (Check all that apply) Loss Job Loss Agricultural Job Other Water Rate Increase 2. Do you currently have a past due water bill? 3. What is your housing status? YES Renter NO Home Owner 4. Is your water currently shut off? YES Applicant: Do not fill out the information in the shaded region. This section is for office use only. What is the amount of water bill assistance benefit? NO The information on this application will be used to determine and verify my eligibility for assistance. My signature gives consent for this information to be shared with other offices of the state and 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 and federal governments for the purpose of providing services to me and to coordinate, improve and reduce the costs of services under these programs. Applicant's Signature Date Witness' Signature (if signed with an X) PURPOSE: The information you provide will be used to decide if you are eligible for a CSD's Drought Water Assistance Program. 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. 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.

4 Drought Water Assistance Program (DWAP) Water Conservation Tips/Education KEEP FOR YOUR INFORMATION Showers If you use a low-flow showerhead, you can save 15 gallons of water during a 10-minute shower. It takes about 70 gallons of water to fill a bathtub, so showers are generally the more water-efficient way to bathe. Save by turning off the tap while brushing your teeth. Turn off shower except for getting wet and rinsing. Laundry Dishes Nearly 22% of indoor home water use comes from doing laundry. Save water by making sure to adjust the settings on your machine to the proper load size. Most front-loading machines are energy and water-efficient, using just over 20 gallons a load, while most top loading machines, unless they are energy-efficient, use 40 gallons per load. Energy Star dishwashers use about 4 gallons of water per load, and even standard machines use only about 6 gallons. Hand washing generally uses about 20 gallons of water each time. Dishwashing is a relatively small part of your water footprint less than 2% of indoor use but there are always ways to conserve. Using a machine is actually more water efficient than hand washing, especially if you run full loads. Faucets & Leaks Yard & Pools Put faucet aerators on sink faucets, 192 gallons a month wasted by a dripping faucet. We re more likely to notice leaks indoors, but don t forget to check outdoor faucets, sprinklers and hoses for leaks. 25 gallons a day are saved if watering is done before 8 a.m. 16 gallons a day benefit of fixing broken sprinklers, adjusting spray to avoid waste, and repairing leaks. The average pool takes 22,000 gallons of water to fill, and if you don t cover it, hundreds of gallons of water per month can be lost due to evaporation. You can find more water conservation tips on the following websites: Have you been affected by drought? These Agencies can help with food: The Holy Family Table St. Joachim s Church 401 West 5 th Street, Madera Madera Coalition for Community Justice 123 North B Street, Madera

5 Programa de Asistencia de la Sequía de Agua (DWAP) Consejos de Conservación del Agua/Educación Retenga para su información Regadera Si utiliza una regadera de bajo corriente, puede ahorrar 15 galones de agua durante una ducha de 10 minutos. Se lleva cerca de 70 galones de agua para llenar una bañera, así que las regaderas son generalmente la manera más eficiente para bañarse. Ahorre cerrando la llave mientras se cepilla los dientes. Apague la regadera excepto para mojarse y enjuagarse. Lavandería Vajillas Casi el 22% del uso de agua en el hogar viene de lavar la ropa. Ahorre agua, asegurándose de ajustar la configuración de la máquina para el tamaño de la carga adecuada. La mayoría de las máquinas de carga frontal son de energía y uso de agua eficiente, usando poco más de 20 galones por carga. Mientras que la mayoría de las máquinas de carga superior usan más, a menos que sean energéticamente eficientes, usan 40 galones por carga. Puede encontrar más consejos de conservación de agua en las siguientes páginas web: Lavaplatos Energy Star utilizan cerca de 4 galones de agua por carga y también las máquinas estándar utilizan solamente cerca de 6 galones. El lavado de manos generalmente utiliza unos 20 galones de agua cada vez. El lavaplatos es una parte relativamente pequeña de su consumo mínimo de agua, -el 2% de uso en interiores, pero siempre hay maneras de conservar. Usando una máquina es en realidad más eficiente que el lavado de las manos, especialmente si se usan con cargas completas. Llaves Y Goteras Ponga aireadores de llaves en grifos del fregadero, -192 galones al mes desperdiciado por un grifo que gotea. Es más probable notar fugas en el interior de la casa, pero no se olvide de revisar las llaves de agua exterior, aspersores y mangueras en busca de goteos. Patios Y Piscinas 25 galones al día se ahorran si el riego se realiza antes de las 8 am, -16 galones al día se benefician arreglando los aspersores rotos, ajustando aerosol para evitar el desperdicio, y la reparación de goteos. La piscina tiene en promedio 22 mil galones de agua, y si no lo cubre, cientos de galones de agua al mes se pierde debido a la evaporación. Ha sido afectado por la sequía? Estas agencias pueden ayudarle con alimentos: Santa Mesa Familiar Iglesia St. Joachim s 401 West 5th Street, Madera Coalición Madera de Justicia de la Comunidad 123 North B Street, Madera

6 Household Members/Miembros del Hogar Questions You 1 Preguntas Usted Client Tracking Form Other person 2 Other person 3 Other person 4 Last Name/Apellido Name/Nombre Date of Birth/ Fecha de Nacimiento Gender/Sexo Are you disabled? Está incapacitado? Age/Edad Age/Edad Age/Edad Age/Edad Male / Female Male / Female Male / Female Male / Female Ethnicity/Etnicidad [ ]Caucasian [ ]Hispanic [ ]Caucasian [ ]Hispanic [ ]Caucasian [ ]Hispanic [ ]Caucasian [ ]Hispanic [ ]Black [ ]Other: [ ]Black [ ]Other: [ ]Black [ ]Other: [ ]Black [ ]Other: Education (last grade) Ultimo año de escuela Health insurance? Tiene seguro médico? Questions Preguntas Other person 5 Other person 6 Other peson 7 Other person 8 Last Name/Apellido Name/Nombre Date of Birth/ Fecha de Nacimiento Age/Edad Age/Edad Age/Edad Age/Edad Gender/Sexo Male / Female Male / Female Male / Female Male / Female Are you disabled? Está incapacitado? Ethnicity/Etnicidad Education (last grade) Ultimo año de escuela Health insurance? Tiene seguro médico? []Caucasian []Hispanic []Caucasian []Hispanic []Caucasian []Hispanic []Caucasian []Hispanic []Black []Other: []Black []Other: []Black []Other: []Black []Other: What type of utility service do you use? (check only one) Qué tipo de servicio de utilidad se usa en casa? (marque solo uno) [] Gas & Electric/Gas y Electricidad [] Electric Only/ Electricidad Únicamente [] Electric & Propane/Electricidad y Gas Propano []Electric, Propane and Wood/Electricidad, Gas Propano y Madera Primary Source of Income: (check only one) / Fuente principal de ingresos - marque solo uno [] None [] TANF [] SSI [] SSA [] Pension [] GA [] UIB [] Employ [] Other Family Type: [ ] Single Parent Female [ ] Single Parent Male [ ] Two Parent [ ] Single Person [ ] Couple [ ] Other Tipo de Familia: Madre Soltera Padre Soltero Dos Padres Soltero/a Pareja Otro Do you/usted: [ ] Rent your home?/renta su casa? [ ] Own your home?/es dueño de su casa? [ ] Other/Otro Is your family/es su familia: [ ]Migrant Farmworkers/Campesinos Migrantes [ ] Seasonal Farmworkers/Campesinos de Temporada [ ] None/Ninguno Are you receiving the PG&E C.A.R.E. Discount / Recibe el descuento C.A.R.E. de PG&E? Yes/Si [ ] No [ ] Do you currently have a child enrolled in the Head Start Program? [ ] Yes [ ] No Actualmente tiene algún niño inscrito en el programa Head Start? Si No Center/Centro

7 Drought Water Assistance Program (DWAP) Programa de Asistencia de la Sequía de Agua Client Education - Water Conservation Tips Educación al Cliente - Conservación del Agua ENGLISH I acknowledge that I have read the following: Written information that describes water conservation tips that can decrease the water consumption of the household. ESPAÑOL - Yo certifico que he recibido lo siguiente: Información por escrito que describe consejos para la conservación del agua que pueden reducir el consumo de agua de la casa. By signing this form, I affirm that I believe these facts are accurate and true. I give the Service Provider my permission to verify this information. I may be held liable under federal or state law for knowingly making false or fraudulent statements. Al firmar este formulario, yo afirmo que yo creo que estos hechos son exactos y veraces. Doy al Proveedor de Servicios mi permiso para verificar esta información y puedo ser responsable bajo la ley federal o estatal por dar declaraciones falsas o fraudulentas. Signature/Firma Date/Fecha