Low Income Home Energy Assistance Program

Tamaño: px
Comenzar la demostración a partir de la página:

Download "Low Income Home Energy Assistance Program"

Transcripción

1 Low Income Home Energy Assistance Program 2014

2 ATTENTION LIHEAP APPLICANTS! Please be aware that this is NOT an emergency assistance program and it will take anywhere from days (from the date your application is processed) for the credit to show up on your PG&E bill. It is your responsibility to continue making payments on your utility bill. 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. Note: Not all applicants are eligible for assistance. Applications must meet criteria established as a priority (Federal priority or high energy burden). If your application cannot be processed, you will receive a letter in the mail with details. 48 Hour Notices and Shut-offs are done by appointment ONLY. If you have a 48-Hour notice or a Shut-off, please call our office to schedule an appointment at (559)

3 LIHEAP Program Criteria Services are available to income eligible persons residing in Madera County Applicant must reside 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. Mail/bring the following Return completed and signed application and Client Tracker forms Provide COPY of the APPLICANT S Social Security card Provide ALL proof of total household income for the past 6 weeks of the date of submission (COPIES of check stubs, award letters for SSI/SSP/SSA, unemployment check stubs, general relief letters, pensions, and or passport to services for TANF for all household members) Provide a copy of a COMPLETE PG&E bill (regular bills only) AND propane delivery tag ALL INFORMATION PROVIDED IS CONFIDENTIAL The LIHEAP program does not assist with 15-Day notices or closed utility accounts. Applications will be accepted until funds have been exhausted. Questions, call (559)

4 Low Income Home Energy Assistance Program Energy Conservation Tips Lighting Turn off all lights not in use, even if you leave the room for a few minutes. Reduce wattage of bulbs whenever possible. Use one bulb when possible. Two 60 watt bulbs use more than one 100 watt bulb. Use fluorescent lamps whenever possible. Fluorescent lamps use 1/3 the energy of an incandescent bulb. Cooking When using your oven, try using as much oven space as possible. Cook whole meals or several meals at once. Cover pots with a lid when cooking. Also, use a burner that is slightly smaller than the pot. Turn the oven off minutes before cooking is done. Also turn off burners before the end of cooking time. When boiling or steaming, burners can be turned down to low so that it simmers. Water Heater Space Heater Turn your hot water heater to 120 degrees or lower. Repair water leaks and drips as soon as possible. Have your water heater on only when you re in the home not on vacation. It takes approximately one hour to heat the contents of the water heater. Take shorter showers. Take showers instead of baths. Wash clothes in cold water. Use only full loads for washing machine and dishwashers. Turning the thermostat from degrees can cut your heating bill by 20%. Use a small space heater to keep you warm instead of heating the whole house. Heat only the rooms that are in use. Wear warmer clothes around the house and use blankets whenever possible. Conserve heat by closing curtains when direct sunlight is not available. A rolled up towel placed at the bottom of your door will help reduce drafts. Refrigerator Check your seal or gasket on your refrigerator door. It should be replaced if you can easily remove a piece of paper out from the refrigerator door. The temperature of your refrigerator should be between degrees. The freezer can be between 0-10 degrees. Other Clean the dryer filter after each use. Dry clothes outside whenever possible or use a clothes dryer rack inside. You can find more energy conservation tips on

5 Department of Community Services and Development Energy Intake Form CSD 43 (01/2014) Agency: CAP of Madera Intake Initials: Intake Date: Eligibility Cert Date: First Name Middle Initial Last Name Date of Birth M M D D Y Y Priority Points: Job Control Code A.C.C. 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: 2 years old or younger Ages 3-5 years Ages 6-18 years Ages (Adult) Ages 60 or older (Elderly) Disabled Native American Limited-English Speaking Seasonal or Migrant Farmworker * Questions 1-5 (below) are MANDATORY fields. INCOME Enter the total number of household members who receive income --> Enter total gross monthly income for all people living in the household: TANF SSI/SSP SSA/SSDI Paycheck(s) Interest Pension Other TOTAL INCOME UTILITY BILL DISCOUNT You may be eligible for a discount on your monthly utility bill! Contact your local utility company and ask about reduced rate programs. Which utility company do you want paid? Account Number: Name of customer on the utility bill: Check here if your utilities are included in rent or sub-metered. Check here if utilities are all electric 1. What is the main fuel you use to HEAT your home? (SELECT ONLY ONE ) Natural Gas Electricity Propane Fuel Oil Wood Kerosene Other Fuel Unknown 2. In addition to the main heating fuel you listed in Question 1, do you ever use any of the following to HEAT your home (you can check more than one): Electricity (such as space heaters) Wood (in a fireplace or wood stove) N/A 3. If you chose NATURAL GAS or ELECTRICITY in Question 1: Do you currently have a past due notice? YES NO N/A Is your gas or electricity currently shut off / disconnected? YES NO N/A 4. If you chose PROPANE, FUEL OIL, WOOD, KEROSENE or OTHER FUEL in Question 1: Approximately how many days until you run out of fuel completely. (enter number of days) : N/A Are you currently out of fuel? YES NO N/A 5. Are you or someone in your household CURRENTLY receiving CalFresh (Food Stamps)? YES 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. 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 if my application for LIHEAP/DOE 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 received. 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 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 on this application is true, correct, and that the funds received will be used solely for the purpose of paying my energy costs. Applicant's Signature Date Witness' Signature (if signed with an X) AGENCY NAME: Community Services and Development (CSD). UNIT RESPONSIBLE FOR MAINTENANCE: Home Energy Assistance Program (HEAP). AUTHORITY: Government Code Section (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. Applicant: Do not fill out the information below. Cash Assistance being provided under which program --> This section is for official use only. HEAP Fast Track Supplement Total Benefit HEAP WPO ECIP WPO Referral --> Home referred for weatherization Referred for ECIP HCS Home already weatherized Weatherization being billed under which program --> DOE LIHEAP WX ECIP HCS Type of Dwelling: MFD - Owner, 2-4 units Mobile Home - Owner Shelter: # of units Unoccupied MFD: 2-4 units SFD - Owner, 1 unit MFD - Rental, 2-4 units Mobile Home - Rental Total # of residents: Unoccupied MFD: > 5 units SFD - Rental, 1 unit MFD - Owner, 5 or more units MFD - Rental, 5 or more units Energy Cost = Energy Burden = % Agency Defined Priorities: Medically Needy Frail Elderly Severe Financial Hardship Hard To Reach Priority Offsets

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 Age/Edad Age/Edad Age/Edad Age/Edad Male / Female Male / Female Male / Female Male / Female Are you disabled? Yes / No Yes / No Yes / No Yes / No Está incapacitado? 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? Yes / No Yes / No Yes / No Yes / No 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? Yes / No Yes / No Yes / No Yes / No []Caucasian []Hispanic []Caucasian []Hispanic []Caucasian []Hispanic []Caucasian []Hispanic []Black []Other: []Black []Other: []Black []Other: []Black []Other: Yes / No Yes / No Yes / No Yes / No 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 Fam. [ ] Single Parent M. [ ] 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 ENGLISH - I acknowledge that I have read the following: Low Income Home Energy Assistance Program Programa de Asistencia de Energía Para Hogares de Bajos Ingresos Client Education Energy Counseling Educación al Cliente Consejos de Energía Written information that describes energy-saving conservation tips that can decrease the energy consumption of the household. LIHEAP/Financial budgeting in order to assist clients in achieving self-sufficiency. If your application is selected for weatherization, you can expect to receive one or more of the following services: (Please check the box below if you wish to be referred for weatherization) weatherization assessment weather stripping of door water heater blanket attic insulation caulking of windows energy saving shower head other energy saving measures ESPAÑOL - Yo certifico que he leído lo siguiente: La información escrita que describe consejos de conservación de ahorro de energía que pueden disminuir el consumo de energía del hogar. LIHEAP / Presupuesto Financiero con el fin de ayudar a los clientes en el logro de la autosuficiencia. Si su aplicación es seleccionada para la climatización, puede esperar recibir uno o más de los siguientes servicios: (Por favor marque la caja debajo si gusta ser referido para la climatización) Evaluación de climatización burletas de las puertas cobija del calentador de agua insolación del ático sellos alrededor de las ventanas regadera de ducha otras medidas de ahorro de energía Do you want your application to be referred for weatherization services? Quiere que se considere su aplicación para servicios de climatización? Check one/marque Una [ ] Yes / Si [ ] No (Not everyone is selected/no todos son seleccionado) Signature / Firma Date / Fecha

8 KEEP FOR YOUR INFORMATION Low Income Home Energy Assistance Program / Financial Budgeting Programa de Asistencia de Energia para Hogares de Bajos Ingresos / Presupuesto Financiero RETENGA PARA SU INFORMACION Disposible Income / Ingresos Disponibles Net income from work (after taxes) Ingresos de trabajo despues de impuestos Other income Otros ingresos Total disposible income Ingreso total disponible Example Ejemplo 1, ,250 Month 1 Mes 1 Month 2 Mes 2 Month 3 Mes 3 Budget Expenses / Gastos del Presupuesto Rent or Mortgage Renta o Hipoteca 425 Utilities (Use a high average of PG&E, water, propane, etc.) Utilidades (Use un promedio alto de luz, agua, propano, etc.) 80 Telephone (Use an average) Telefono (Use un promedio) 40 Food (Use an average) Comida (Use un promedio) 250 Insurance (car, health, life, etc.) Aseguranza (carro, salud, vida, etc.) 74 Car payment / Pago de Carro 200 Gasoline Gasolina 60 Credit Cards Tarjetas de credito 35 Clothing Ropa 20 Entertainment (movies, dinner, trips, etc.) Entretenimiento (peliculas, cenas, paseos, etc.) 30 Other Otros 20 Total Expenses Gastos Totales 1,234 Savings / Ahorros 16 When you have a savings (money left over), this money should be used for a savings account or to pay ahead on existing accounts. Cuando tenga ahorros (dinero despues de pagar sus gastos) deberia usar este dinero para una cuenta de ahorros o para pagar por adelantado una cuenta actual.

9 Low Income Home Energy Assistance Program Programa de Asistencia de Energia para Hogares de Bajos Ingresos Energy Conservation Tips Metodos para Reducir el Consumo de Energia ENGLISH Lighting Turn off all lights not in use. Reduce wattage of bulbs whenever possible. Use fluorescent lamps whenever possible. Fluorescent lamps use 1/3 the energy of an incandescent bulb. Cooking When using your oven, try using as much oven space as possible. Cook whole meals or several meals at once. Cover pots with a lid when cooking. Also, use a burner that is slightly smaller than the pot. ESPAÑOL Iluminacion Apage las luzes que no ocupe. Si es possible, rebaje los vatios de los focos. Use lamparas fosforescentes. Los tubos fosforescentes utilizan una tercer parte de energia que un foco incandescente. Cocinando Cuando utilize un horno, use todo el espacio que sea posible. Cocine comidas enteras o mas de una comida a la vez. Precalentar el horno generalmente no es necesario. Cubra las cazuelas con tapaderas cuando este cocinando. Tambien utilize un quemador mas chico que la cazuela. Water Heater Turn your hot water heater to 120 degrees or lower. Repair water leaks and drips as soon as possible. Have your water heater on only when you re in the home not on vacation. It takes approximately one hour to heat the contents of the water heater. Take shorter showers. Take showers instead of baths. Wash clothes in cold water. Use only full loads for washing machine and dishwashers. Calentador de Agua Ponga la valbula del calentador de agua a 120 gados o menos. Repare goteos y fugas de agua lo mas pronto posible. Solo mantenga su calentador de agua trabajando cuando usted este en casa, no de vacaciones. Toma aproximadamente una hora para que se caliente el agua. Tome menos tiempo para bañarse. Bañese con la regadera y no en la tina. Lave la ropa en agua fria. Utilize la capacidad maxima de la lavadora y la maquina de lavaplatos. Space Heater Turning the thermostat from degrees can cut your heating bill by 20%. Use a small space heater to keep you warm instead of heating the whole house. Heat only the rooms that are in use. Wear warmer clothes around the house and use blankets whenever possible. Conserve heat by closing curtains when direct sunlight is not available. A rolled up towel placed at the bottom of your door will help reduce drafts. Refrigerator Check your seal or gasket on your refrigerator door. It should be replaced if you can easily remove a piece of paper out from the refrigerator door. The temperature of your refrigerator should be between degrees. The freezer can be between 0-10 degrees. Other Clean the dryer filter after each use. Dry clothes outside whenever possible or use a clothes dryer rack inside. You can find more energy conservation tips on Calenton de Espacio Poniendo el termostato de grados reduce el bil de energia por 20%. Utilize un calentador pequeño para calentarse usted y no toda la casa. Caliente los cuartos en uso solamente. Utilize ropa calientita o utilize cobijas cuando se possible. Cierre las cortinas cuando el sol no este directo. Una toalla enrollada al pie de la puerta ayudara reducir que entre el aire. Refrigerador Revise el sello o junta de la puerta del refrigerador. Reemplazcalo si puede mover un papel dentro y fuera de la puerta facilmente. La temperatura del refrigerador deberia estar de grados, el congelador de 0-10 grados. Otros Limpie el filtro de la secadora despues de cada uso. Seque la ropa afuera cuando sea posible. Puede encontrar mas metodos para reducir el consumo de energia en

Low Income Home Energy Assistance Program

Low Income Home Energy Assistance Program Low Income Home Energy Assistance Program 2012 Programa de Asistencia de Energia para Hogares de Bajos Ingresos ATENCION APLICANTES DE LIHEAP! Por favor este consciente que este programa NO es un programa

Más detalles

Low Income Home Energy Assistance Program

Low Income Home Energy Assistance Program Low Income Home Energy Assistance Program 2010 (Programa De Asistencia de Energía Para Hogares de Bajos Ingresos) ! ATENCION APLICANTES DE LIHEAP! Por favor este consciente que este programa NO es un programa

Más detalles

Fondos son LIMITADOS!

Fondos son LIMITADOS! El Programa de Asistencia para el Agua durante la Sequía ayuda a hogares de bajos ingresos impactados por la sequía. El Programa provee asistencia con facturas de agua residenciales actuales, retrasadas,

Más detalles

Low Income Home Energy Assistance Program

Low Income Home Energy Assistance Program Low Income Home Energy Assistance Program 2015 Programa de Asistencia de Energía para Hogares de Bajos Ingresos ATENCION APLICANTES DE LIHEAP! Por favor este consciente que este programa NO es un programa

Más detalles

Guide to Health Insurance Part II: How to access your benefits and services.

Guide to Health Insurance Part II: How to access your benefits and services. Guide to Health Insurance Part II: How to access your benefits and services. 1. I applied for health insurance, now what? Medi-Cal Applicants If you applied for Medi-Cal it will take up to 45 days to find

Más detalles

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

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

Más detalles

TITLE VI COMPLAINT FORM

TITLE VI COMPLAINT FORM [CITY SEAL/EMBLEM] The Capital City of the Palm Beaches TITLE VI COMPLAINT FORM Title VI of the 1964 Civil Rights Act requires that "No person in the United States shall, on the ground of race, color or

Más detalles

Down Payment Assistance Application Packet

Down Payment Assistance Application Packet Down Payment Assistance Application Packet Please assure that all needed items are attached and complete. Please note that your application will not be considered until all documents are received. 1. Down

Más detalles

Programa de Asistencia de Energía del Hogar para personas de Bajos Ingresos (LIHEAP)

Programa de Asistencia de Energía del Hogar para personas de Bajos Ingresos (LIHEAP) Programa de Asistencia de Energía del Hogar para personas de Bajos Ingresos (LIHEAP) Yo,, quien aplico para el programa de LIHEAP el día de / /, entiendo que este no es un programa de emergencia, y se

Más detalles

Puede pagar facturas y gastos periódicos como el alquiler, el gas, la electricidad, el agua y el teléfono y también otros gastos del hogar.

Puede pagar facturas y gastos periódicos como el alquiler, el gas, la electricidad, el agua y el teléfono y también otros gastos del hogar. SPANISH Centrepay Qué es Centrepay? Centrepay es la manera sencilla de pagar sus facturas y gastos. Centrepay es un servicio de pago de facturas voluntario y gratuito para clientes de Centrelink. Utilice

Más detalles

Welcome to the CU at School Savings Program!

Welcome to the CU at School Savings Program! Welcome to the CU at School Savings Program! Thank you for your interest in Yolo Federal Credit Union s CU at School savings program. This packet of information has everything you need to sign your child

Más detalles

Lump Sum Final Check Contribution to Deferred Compensation

Lump Sum Final Check Contribution to Deferred Compensation Memo To: ERF Members The Employees Retirement Fund has been asked by Deferred Compensation to provide everyone that has signed up to retire with the attached information. Please read the information from

Más detalles

Home Energy Assistance Program and Weatherization Application and Supporting Documentation Check List

Home Energy Assistance Program and Weatherization Application and Supporting Documentation Check List Application and Supporting Documentation Check List Home Energy Assistance Program and Weatherization GNC Application: Completed in blue or black ink. Home Energy Assistance Program and Weatherization

Más detalles

El Abecedario Financiero

El Abecedario Financiero El Abecedario Financiero Unidad 4 National PASS Center 2013 Lección 5 Préstamos Vocabulario: préstamo riesgocrediticio interés obligadosolidario A lgunavezpidesdineroprestado? Dóndepuedespedirdinero prestado?

Más detalles

DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS

DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS DEPARTAMENTO ESTATAL DE SERVICIOS DE SALUD DE TEXAS DAVID L. LAKEY, M.D. DIRECTOR P.O. Box 149347 Austin, Texas 78714-9347 1-888-963-7111 TTY (teletipo): 1-800-735-2989 www.dshs.state.tx.us 1 de marzo,

Más detalles

2015 16 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program

2015 16 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program 2015 16 Student Eligibility Verification Advanced Placement (AP) and/or International Baccalaureate (IB) Exams AP Exam IB Exam AP and IB Exams I. Student Information Last Name First Name MI Grade High

Más detalles

Complete por favor todas las paginas y envielas a nuestro correo postal: Home Energy

Complete por favor todas las paginas y envielas a nuestro correo postal: Home Energy Dear Valued Customer: Eversource is offering free weatherization services designed to lower your energy bill. The HES-IE program is available to renters or homeowners with a GROSS income at or below 60

Más detalles

This grant only covers deliveries to the building, up to the grant award.

This grant only covers deliveries to the building, up to the grant award. Citizens Energy /CITGO Petroleum Oil Heat Program 2015 EXPLANATION OF GRANT TERMS & CONDITIONS FOR BOARD MEMBERS If Awarded A Grant, HDFC s Agree To The Following Grant Regulations: This grant only covers

Más detalles

IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR

IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR IRS DATA RETRIEVAL NOTIFICATION DEPENDENT STUDENT ESTIMATOR Subject: Important Updates Needed for Your FAFSA Dear [Applicant], When you completed your 2012-2013 Free Application for Federal Student Aid

Más detalles

EMPLOYER & EMPLOYEE RETIREMENT PLAN TAX CREDITS

EMPLOYER & EMPLOYEE RETIREMENT PLAN TAX CREDITS EMPLOYER & EMPLOYEE RETIREMENT PLAN TAX CREDITS For employers who set up and maintain retirement plans, the setup costs, annual administrative costs, and retirement-related employee education costs are

Más detalles

Low-Income Telephone and Electric Discount Programs Enrollment Form (LITE-UP) For Questions, Call LITE-UP Texas toll-free at 1-866-454-8387

Low-Income Telephone and Electric Discount Programs Enrollment Form (LITE-UP) For Questions, Call LITE-UP Texas toll-free at 1-866-454-8387 Low-Income Telephone and Electric Discount Programs Enrollment Form (LITE-UP) For Questions, Call LITE-UP Texas toll-free at 1-866-454-8387 January 27, 2009 Courtesy_Title Full_Name 1 Mail_Address_2 Mail_Address_1

Más detalles

Peru Tourist visa Application for citizens of Costa Rica living in Ontario - Ottawa, Gatineau

Peru Tourist visa Application for citizens of Costa Rica living in Ontario - Ottawa, Gatineau Peru Tourist visa Application for citizens of Costa Rica living in Ontario - Ottawa, Gatineau Please enter your contact information Name: Email: Tel: Mobile: The latest date you need your passport returned

Más detalles

PB #11-111-OPE. Attachment: Please use Print on M-687r Referral to Treatment Program (Rev. 11/30/11) (Rev. 11/30/11)

PB #11-111-OPE. Attachment: Please use Print on M-687r Referral to Treatment Program (Rev. 11/30/11) (Rev. 11/30/11) FAMILY INDEPENDENCE ADMINISTRATION Matthew Brune, Executive Deputy Commissioner James K. Whelan, Deputy Commissioner Policy, Procedures, and Training Stephen Fisher, Assistant Deputy Commissioner Office

Más detalles

CNS Paragraph Form Date: 09.02.11

CNS Paragraph Form Date: 09.02.11 CNS Paragraph Form Date: 09.02.11 Program Area 03 (01=PA, 02=FS, 03=MA, 04=HP) Paragraph Number U0223 Version Number 00001 Effective Date 2011 Title Administrative Renewal for Aged, Blind and Disabled,

Más detalles

Voter Information Guide and Sample Ballot

Voter Information Guide and Sample Ballot Voter Information Guide and Sample Ballot Special Election San Bernardino Mountains Community Hospital District Tuesday, June 4, 2013 Elections Office of the Registrar of Voters 777 East Rialto Ave. San

Más detalles

Required Documentation for Charity Care

Required Documentation for Charity Care Patchogue, New York 11772 Required Documentation for Charity Care The completed signed application listing all family members, must be filled out and returned to the Patient Financial Services Department

Más detalles

RENT CONTROL BOARD OF THE TOWN OF WEST NEW YORK, N.J. 428-60 TH STREET WEST NEW YORK, N.J. 07093-2231 (201) 295-5290/91/92

RENT CONTROL BOARD OF THE TOWN OF WEST NEW YORK, N.J. 428-60 TH STREET WEST NEW YORK, N.J. 07093-2231 (201) 295-5290/91/92 FELIX E. ROQUE, MD MAYOR DEPT. OF PUBLIC AFFAIRS RENT CONTROL BOARD RENTAL AGREEMENT APPLICATION NAME OF ADDRESS OF LANDLORD: PROPERTY ADDRESS: APARTMENT #: 3 COPIES (1) Original rental agreement signed

Más detalles

2014 15 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program

2014 15 Student Eligibility Verification Advanced Placement/International Baccalaureate Test Fee Program 2014 15 Student Eligibility Verification Advanced Placement (AP) and/or International Baccalaureate (IB) Exams þ AP Exam IB Exam AP and IB Exams I. Student Information Last Name First Name MI Grade High

Más detalles

TITLE VI COMPLAINT FORM

TITLE VI COMPLAINT FORM TITLE VI COMPLAINT FORM Before filling out this form, please read the Arcata and Mad River Transit System Title VI Complaint Procedures located on our website or by visiting our office. The following information

Más detalles

Instructions on How to Access and Print Your W2 Statement for Active or Terminated Employees

Instructions on How to Access and Print Your W2 Statement for Active or Terminated Employees Instructions on How to Access and Print Your W2 Statement for Active or Terminated Employees SUBJECT: ACCESSING AND PRINTING YOUR W2 STATEMENT AS AN ACTIVE EMPLOYEE PURPOSE: This document outlines the

Más detalles

www.deltadentalins.com/language_survey.html

www.deltadentalins.com/language_survey.html Survey Code: Survey 1 February 6, 2008 Dear Delta Dental Enrollee: Recent changes in California law will require that all health care plans provide language assistance to their plan enrollees beginning

Más detalles

Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts?

Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts? Albany Housing Authority RESIDENT COMMISSIONER ELECTION Are you interested in helping to GOVERN the Authority, DEVELOP current and future programs, and APPROVE contracts? RUN FOR RESIDENT COMMISSIONER

Más detalles

INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN

INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN INFORMACIÓN PARA ABRIR UNA GUARDERÍA DE NIÑOS PARA FAMILIAS O GRUPOS EN LA CIUDAD DE ALLENTOWN Informacion importante de saber: Una guarderia de niños para familias consite de un niño hasta 6 niños. Una

Más detalles

Financial Affidavit for Child Support, DC 6:5(2) Declaración Jurada de Finanzas para Manutención de Menores, DC 6:5(2).

Financial Affidavit for Child Support, DC 6:5(2) Declaración Jurada de Finanzas para Manutención de Menores, DC 6:5(2). IN THE DISTRICT CURT F CUNTY, NEBRASKA (county where Complaint filed) EN LA CRTE DE DISTRIT DEL CNDAD DE, NEBRASKA (condado donde se entabló la Demanda), ) (your full name) (su nombre completo) ) Plaintiff,/

Más detalles

HABERSHAM COUNTY SCHOOLS LAS ESCUELAS DEL CONDADO DE HABERSHAM ENROLLMENT/STUDENT INFORMATION FORM FORMA DE MATRICULACION

HABERSHAM COUNTY SCHOOLS LAS ESCUELAS DEL CONDADO DE HABERSHAM ENROLLMENT/STUDENT INFORMATION FORM FORMA DE MATRICULACION HABERSHAM COUNTY SCHOOLS LAS ESCUELAS DEL CONDADO DE HABERSHAM ENROLLMENT/STUDENT INFORMATION FORM FORMA DE MATRICULACION CHILD LIVES IN SCHOOL DISTRICT (PLEASE GIVE NAME OF ELEMENTARY SCHOOL) (distrito

Más detalles

Purpose of Sliding Scale Policy and Procedure Disclaimer Policy

Purpose of Sliding Scale Policy and Procedure Disclaimer Policy San Luis Valley Health s Behavioral Health department offers a sliding fee discount program to eligible patients. If you would like more information, please call 589-8008, or ask one of our Admitting Clerks

Más detalles

Eligibility Screening Sheet Hoja de Evaluación de Egibilidad

Eligibility Screening Sheet Hoja de Evaluación de Egibilidad The Peninsula Of Business And Technology Department of Administration Division of Community Development & Grants Management CITY OF BAYONNE 555 KENNEDY BLVD BAYONNE, NJ 07002-3898 TEL. (201) 437-7222 FAX

Más detalles

MajestaCare Healthy Baby Program

MajestaCare Healthy Baby Program MajestaCare Healthy Baby Program Helping you have a healthy baby Para que tenga un bebé saludable Your baby s provider After your baby becomes a member of MajestaCare health plan, you will get a letter

Más detalles

SOUTHERN CALIFORNIA GAS COMPANY Revised CAL. P.U.C. SHEET NO. 51492-G LOS ANGELES, CALIFORNIA CANCELING Revised CAL. P.U.C. SHEET NO.

SOUTHERN CALIFORNIA GAS COMPANY Revised CAL. P.U.C. SHEET NO. 51492-G LOS ANGELES, CALIFORNIA CANCELING Revised CAL. P.U.C. SHEET NO. SOUTHERN CALIFORNIA GAS COMPANY Revised CAL. P.U.C. SHEET NO. 51492-G LOS ANGELES, CALIFORNIA CANCELING Revised CAL. P.U.C. SHEET NO. 50302-G SAMPLE FORMS: APPLICATIONS Post-Enrollment Verification CARE

Más detalles

Chattanooga Motors - Solicitud de Credito

Chattanooga Motors - Solicitud de Credito Chattanooga Motors - Solicitud de Credito Completa o llena la solicitud y regresala en persona o por fax. sotros mantenemos tus datos en confidencialidad. Completar una aplicacion para el comprador y otra

Más detalles

ANNUAL REPORT OF GUARDIAN ON CONDITION OF WARD/INCAPACITATED PERSON INFORME ANUAL DEL TUTOR SOBRE LA CONDICIÓN DEL PUPILO/PERSONA INCAPACITADA/INHÁBIL

ANNUAL REPORT OF GUARDIAN ON CONDITION OF WARD/INCAPACITATED PERSON INFORME ANUAL DEL TUTOR SOBRE LA CONDICIÓN DEL PUPILO/PERSONA INCAPACITADA/INHÁBIL Nebraska State Court Form REQUIRED Formulario del Tribunal del Estado de Nebraska REQUERIDO ANNUAL REPORT OF GUARDIAN ON CONDITION OF WARD/INCAPACITATED PERSON INFORME ANUAL DEL TUTOR SOBRE LA CONDICIÓN

Más detalles

Applicants who wish to apply to either program MUST meet all of the following criteria:

Applicants who wish to apply to either program MUST meet all of the following criteria: PAGE PROGRAM MINIMUM ELIGIBILITY REQUIREMENTS Applicants who wish to apply to either program MUST meet all of the following criteria: Annual income per client household size must fall within the following

Más detalles

Affordable Care Act Informative Sessions and Open Enrollment Event

Affordable Care Act Informative Sessions and Open Enrollment Event 2600 Cedar Ave., P.O. Box 2337, Laredo, TX 78044 Hector F. Gonzalez, M.D., M.P.H Tel. (956) 795-4901 Fax. (956) 726-2632 Director of Health News Release. Date: February 9, 2015 FOR IMMEDIATE RELEASE To:

Más detalles

Welcome Savers! 1. Fill out application form if you re not already a Yolo FCU member.

Welcome Savers! 1. Fill out application form if you re not already a Yolo FCU member. Welcome Savers! Yolo Federal Credit Union and Montgomery Elementary School have teamed up again this year to bring you our school saving program! It s easy to participate... 1. Fill out application form

Más detalles

Screener for Peer Supporters

Screener for Peer Supporters Screener for Peer Supporters Primary Recruiter: Secondary Recruiter: Potential Peer Supporter Name: Phone #1: Home/Cell Phone #2: Home/Cell Address: City: Zip: Contact 1: Date: / / Contact 2: Date: / /

Más detalles

ALERT. Customers inquiring about the letter must be asked if he/she has filed 2014 tax return and:

ALERT. Customers inquiring about the letter must be asked if he/she has filed 2014 tax return and: ALERT Customers who received a premium tax credit in 2014 and are preparing to renew his/her health coverage for 2016 are required to have filed his/her 2014 taxes in order to continue receiving his/her

Más detalles

Hola. A continuación encontrará algunas preguntas que debo hacerle acerca de su hogar y propiedad después del desastre.

Hola. A continuación encontrará algunas preguntas que debo hacerle acerca de su hogar y propiedad después del desastre. Hola. A continuación encontrará algunas preguntas que debo hacerle acerca de su hogar y propiedad después del desastre. Hello. There are some questions I need to ask you about damage to your home and property

Más detalles

News Flash! Primary & Specialty Care Providers. Sharp Health Plan. Date: February 17, 2012. Subject: Member Grievance Forms

News Flash! Primary & Specialty Care Providers. Sharp Health Plan. Date: February 17, 2012. Subject: Member Grievance Forms I M P O R T A N T News Flash! A FAX Publication for Providers of Sharp Health Plan To: From: Primary & Specialty Care Providers Sharp Health Plan Date: February 17, 2012 Subject: Member Grievance Forms

Más detalles

OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal.

OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal. OJO: Todos los formularios deberán llenarse en inglés. De lo contrario, no se le permitirá presentar sus documentos ante la Secretaría del Tribunal. For Clerk s Use Only (Para uso de la Secretaria solamente)

Más detalles

PRINTING INSTRUCTIONS

PRINTING INSTRUCTIONS PRINTING INSTRUCTIONS 1. Print the Petition form on 8½ X 11inch paper. 2. The second page (instructions for circulator) must be copied on the reverse side of the petition Instructions to print the PDF

Más detalles

Person ID:
, Mailed:

Person ID: <MPI_ID> <Primary Applicant/AREP FMLNS> <Address Line 1> <Address Line 2> <City>, <State> <Zip> Mailed: <Current Date> Person ID: , Mailed: Your HUSKY Health Coverage is Scheduled to End on August 31st Dear

Más detalles

AVISO IMPORTANTE REFERENTE A SU CASO DE ASISTENCIA GENERAL

AVISO IMPORTANTE REFERENTE A SU CASO DE ASISTENCIA GENERAL BERGEN COUNTY BOARD OF SOCIAL SERVICES 216 STATE ROUTE 17 NORTH ROCHELLE PARK, NJ 07662-3300 Tel. (201) 368-4200 FAX: (201) 368-8721 Internet: www.bcbss.com 8 AVISO IMPORTANTE REFERENTE A SU CASO DE ASISTENCIA

Más detalles

Home Energy Assistance Program

Home Energy Assistance Program Home Energy Assistance Program Please complete and mail in the following documents to submit your application Programa de Asistencia de Energía Por favor complete y envíe los siguientes documentos para

Más detalles

IMMIGRATION Canada. Temporary Resident Visa. Mexico City Visa Office Instructions. Table of Contents IMM 5878 E (10-2015)

IMMIGRATION Canada. Temporary Resident Visa. Mexico City Visa Office Instructions. Table of Contents IMM 5878 E (10-2015) IMMIGRATION Canada Table of Contents Document Checklist Temporary resident visa (available in Spanish) Emergency Processing Request Form Temporary Resident Visa Mexico City Visa Office Instructions This

Más detalles

MANUAL EASYCHAIR. A) Ingresar su nombre de usuario y password, si ya tiene una cuenta registrada Ó

MANUAL EASYCHAIR. A) Ingresar su nombre de usuario y password, si ya tiene una cuenta registrada Ó MANUAL EASYCHAIR La URL para enviar su propuesta a la convocatoria es: https://easychair.org/conferences/?conf=genconciencia2015 Donde aparece la siguiente pantalla: Se encuentran dos opciones: A) Ingresar

Más detalles

Administración de ingresos. Voluntaria

Administración de ingresos. Voluntaria Administración de ingresos Voluntaria Qué es Administración de ingresos (Income Management)? La Administración de ingresos (Income Management) es una manera de ayudarle a administrar su dinero a fin de

Más detalles

Daly Elementary. Family Back to School Questionnaire

Daly Elementary. Family Back to School Questionnaire Daly Elementary Family Back to School Questionnaire Dear Parent(s)/Guardian(s), As I stated in the welcome letter you received before the beginning of the school year, I would be sending a questionnaire

Más detalles

School Preference through the Infinite Campus Parent Portal

School Preference through the Infinite Campus Parent Portal School Preference through the Infinite Campus Parent Portal Welcome New and Returning Families! Enrollment for new families or families returning to RUSD after being gone longer than one year is easy.

Más detalles

ANTES DE ENTREGAR SU SOLICITUD! ASISTENCIA. STONEBRIAR COMMUNITY CHURCH (SCC) NO OFRECE AYUDA INMEDIATA. AYUDA. APROPIADOS.

ANTES DE ENTREGAR SU SOLICITUD! ASISTENCIA. STONEBRIAR COMMUNITY CHURCH (SCC) NO OFRECE AYUDA INMEDIATA. AYUDA. APROPIADOS. ATENCIÓN!!! FAVOR DE LEER Y PONER SUS INÍCIALES EN ESTA PÁGINA ANTES DE ENTREGAR SU SOLICITUD! SI USTED NO PROVEE LO REQUERIDO, NO RECIBIRÁ ASISTENCIA. STONEBRIAR COMMUNITY CHURCH (SCC) NO OFRECE AYUDA

Más detalles

Program Guidelines: 1. The program must be primarily for the general public low income family whose intent is to maintain their pet in their home.

Program Guidelines: 1. The program must be primarily for the general public low income family whose intent is to maintain their pet in their home. ATTACHMENT A Program Guidelines: The primary purpose of this program is to prevent animal surrenders due to a family s inability to feed their pet(s). The following procedures are requested of all DaisyCares

Más detalles

El Estado de Nevada le prestará ayuda con el costo de medicamentos recetados si califica:

El Estado de Nevada le prestará ayuda con el costo de medicamentos recetados si califica: Necesita ayuda para pagar sus medicamentos recetados? SeniorRx puede ser la solución! El Estado de Nevada le prestará ayuda con el costo de medicamentos recetados si califica: - Edad 62 años o más -Residentes

Más detalles

AGENCY POLICY: REVIEW OF NOTICE OF PRIVACY PRACTICES

AGENCY POLICY: REVIEW OF NOTICE OF PRIVACY PRACTICES AGENCY POLICY: REVIEW OF NOTICE OF PRIVACY PRACTICES SCOPE OF POLICY This policy applies to all agency staff members. Agency staff members include all employees, trainees, volunteers, consultants, students,

Más detalles

Solicitud para el Programa de Child Care Subsidies and Referrals (CCSR)

Solicitud para el Programa de Child Care Subsidies and Referrals (CCSR) GAP CLIFF FRSFF SN Application for Child Care Subsidy and Referrals (CCSR) Program Parent/guardian info: Last Name: First Name: Middle Initial: Sex: Birth date: E-mail Address: Residence Address: City:

Más detalles

Cal Grant GPA Electronic Submission and Opt-out Notification As of 10.13.15

Cal Grant GPA Electronic Submission and Opt-out Notification As of 10.13.15 12338 McCourtney Road Grass Valley, CA 95949 Phone: 530-272-4008 Fax: 530-272-4009 www.johnmuircs.com Cal Grant GPA Electronic Submission and Opt-out Notification As of 10.13.15 Assembly Bill 2160, commonly

Más detalles

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION FORM 16-1 AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Completion of this document authorizes the disclosure and use of health information about you. Failure to provide all information requested

Más detalles

IMMIGRATION Canada. Study Permit. Buenos Aires Visa Office Instructions. Table of Contents. For the following countries:

IMMIGRATION Canada. Study Permit. Buenos Aires Visa Office Instructions. Table of Contents. For the following countries: IMMIGRATION Canada Table of Contents Document Checklist Study Permit (available in Spanish) Study Permit Buenos Aires Visa Office Instructions For the following countries: Argentina, Chile, Easter Island,

Más detalles

Janssen Prescription Assistance. www.janssenprescriptionassistance.com

Janssen Prescription Assistance. www.janssenprescriptionassistance.com Janssen Prescription Assistance www.janssenprescriptionassistance.com Janssen Prescription Assistance What is Prescription Assistance? Prescription assistance programs provide financial help to people

Más detalles

Your HUSKY Health Coverage Category is Changing

Your HUSKY Health Coverage Category is Changing Connecticut s Official Health Insurance Marketplace Person ID: , Mailed: Your HUSKY Health Coverage

Más detalles

New Health Insurance Marketplace Coverage Options and Your Health Coverage

New Health Insurance Marketplace Coverage Options and Your Health Coverage New Health Insurance Marketplace Coverage Options and Your Health Coverage Form Approved OMB No. 1210-0149 (expires 11-30-2013) PART A: General Information When key parts of the health care law take effect

Más detalles

Creating your Single Sign-On Account for the PowerSchool Parent Portal

Creating your Single Sign-On Account for the PowerSchool Parent Portal Creating your Single Sign-On Account for the PowerSchool Parent Portal Welcome to the Parent Single Sign-On. What does that mean? Parent Single Sign-On offers a number of benefits, including access to

Más detalles

LOS ANGELES UNIFIED SCHOOL DISTRICT STUDENT EMERGENCY INFORMATION FORM Parent Information: Please fill out completely and sign where indicated. In a major emergency, it is school district policy to retain

Más detalles

Peru Business visa Application

Peru Business visa Application Peru Business visa Application Please enter your contact information Name: Email: Tel: Mobile: The latest date you need your passport returned in time for your travel: Peru business visa checklist Filled

Más detalles

Asistencia para cuidado infantil

Asistencia para cuidado infantil SPANISH Asistencia para cuidado infantil El Gobierno Australiano ofrece una gama de pagos y servicios para ayudar a las familias con los costes de cuidado infantil incluyendo: Child Care Benefit para cuidado

Más detalles

Migrant. Learners Today LEADERS Tomorrow!

Migrant. Learners Today LEADERS Tomorrow! Migrant Learners Today LEADERS Tomorrow! 2014 Migrant Summer Program Language Enrichment for English Language Learners Through Science Themes Students will enhance English language acquisition through

Más detalles

SFGH FHC Healthy Children Vaccination Program Frequently Asked Questions

SFGH FHC Healthy Children Vaccination Program Frequently Asked Questions SFGH FHC Healthy Children Vaccination Program Frequently Asked Questions The Family Health Center (FHC) Healthy Children Vaccination Program at SF General Hospital (SFGH) provides immunization services

Más detalles

Workers Compensation Non-Subscriber Form

Workers Compensation Non-Subscriber Form Workers Compensation Non-Subscriber Form Texas is unique in one very important respect: It s the only state in which employers have the choice to carry workers compensation insurance or not. There are

Más detalles

EL PASO ELECTRIC COMPANY THIRD REVISED SAMPLE FORM NO. 22 CANCELLING SECOND REVISED SAMPLE FORM NO. 22

EL PASO ELECTRIC COMPANY THIRD REVISED SAMPLE FORM NO. 22 CANCELLING SECOND REVISED SAMPLE FORM NO. 22 'FILED IN OFFICE OF WMPUBLIC REG. COMM. EL PASO ELECTRIC COMPANY JAN 17 lu14 THIRD REVISED SAMPLE FORM NO. 22 CANCELLING SECOND REVISED SAMPLE FORM NO. 22 NOTIFY FOR DELINQUENT AMOUNT (IVR OUTBOUND CALL

Más detalles

GOOD NEWS!!! HOUSING AUTHORITY HAS INCREASED ITS PAYMENT STANDARDS FREQUENTLY ASKED QUESTIONS (FAQs) FOR TENANTS

GOOD NEWS!!! HOUSING AUTHORITY HAS INCREASED ITS PAYMENT STANDARDS FREQUENTLY ASKED QUESTIONS (FAQs) FOR TENANTS GOOD NEWS!!! HOUSING AUTHORITY HAS INCREASED ITS PAYMENT STANDARDS FREQUENTLY ASKED QUESTIONS (FAQs) FOR TENANTS 1. WHAT IS THE GOOD NEWS? Effective February 1, 2016, the Housing Authority has increased

Más detalles

Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form

Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form Low-Income Telephone and Electric Discount Programs (LITE-UP) Enrollment Form The Program can: 1. Provide a discount off your monthly telephone bill. 2. Provide a discount on your electric bill if you

Más detalles

Learning Masters. Fluent: Wind, Water, and Sunlight

Learning Masters. Fluent: Wind, Water, and Sunlight Learning Masters Fluent: Wind, Water, and Sunlight What I Learned List the three most important things you learned in this theme. Tell why you listed each one. 1. 2. 3. 22 Wind, Water, and Sunlight Learning

Más detalles

ETHS Home Access Center (HAC) Updating Registration Information for Parents/Guardians

ETHS Home Access Center (HAC) Updating Registration Information for Parents/Guardians ETHS Home Access Center (HAC) Updating Registration Information for Parents/Guardians English Version First (Primero la version en inglés) Segundo la version en español (Spanish Version Second) Table of

Más detalles

Welcome to Borrow-And-Save: A Spring Bank Consumer Loan

Welcome to Borrow-And-Save: A Spring Bank Consumer Loan Welcome to Borrow-And-Save: A Spring Bank Consumer Loan Thank you for considering Spring Bank for a personal installment loan. Borrow-And-Save is designed to help you obtain the loan you need while building

Más detalles

ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights

ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights. ODJFS Bureau of Civil Rights ODJFS Bureau of Civil Rights I NEED AN INTERPRETER, PLEASE. Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of national origin. If you do not speak English well, social services,

Más detalles

\RESOURCE\ELECTION.S\PROXY.CSP

\RESOURCE\ELECTION.S\PROXY.CSP The following is an explanation of the procedures for calling a special meeting of the shareholders. Enclosed are copies of documents, which you can use for your meeting. If you have any questions about

Más detalles

How to make a complaint or provide feedback Family Tax Benefit Part A (FTB Part A)

How to make a complaint or provide feedback Family Tax Benefit Part A (FTB Part A) SPANISH How to make a complaint or provide feedback Family Tax Benefit Part A (FTB Part A) Requisitos El Family Tax Benefit Part A es un pago que se otorga para ayudar a cubrir el costo de la crianza de

Más detalles

FONDO PANAMERICANO LEO S. ROWE / DEPARTAMENTO DE DESARROLLO HUMANO

FONDO PANAMERICANO LEO S. ROWE / DEPARTAMENTO DE DESARROLLO HUMANO FONDO PANAMERICANO LEO S. ROWE / DEPARTAMENTO DE DESARROLLO HUMANO www.oas.org/rowe 1889 F Street, NW, 619, Washington, DC 20006; Tel. (202) 458-6208; Fax (202) 458-3897; E-mail: RoweFund@oas.org APERTURA

Más detalles

INSTRUCTIONS FOR COMPLETING THE UA_SGE_FT_03_FI_IE FORM REGARDING NATURAL PERSONS DATA FOR THE UA SUPPLIERS DATABASE

INSTRUCTIONS FOR COMPLETING THE UA_SGE_FT_03_FI_IE FORM REGARDING NATURAL PERSONS DATA FOR THE UA SUPPLIERS DATABASE INSTRUCTIONS FOR COMPLETING THE UA_SGE_FT_03_FI_IE FORM REGARDING NATURAL PERSONS DATA FOR THE UA SUPPLIERS DATABASE This form is for use by both Spanish and foreign natural persons. Due to the new requirements

Más detalles

Meet the Nest Learning Thermostat

Meet the Nest Learning Thermostat Welcome Guide Meet the Nest Learning Thermostat Display Turns blue when cooling and orange when heating. Status Nest shows you Time-to-Temperature and if it s heating, cooling or using Airwave. Current

Más detalles

Cómo comprar en la tienda en línea de UDP y cómo inscribirse a los módulos UDP

Cómo comprar en la tienda en línea de UDP y cómo inscribirse a los módulos UDP Cómo comprar en la tienda en línea de UDP y cómo inscribirse a los módulos UDP Sistema de registro y pago Este sistema está dividido en dos etapas diferentes*. Por favor, haga clic en la liga de la etapa

Más detalles

Asistencia para alimentos de Iowa (Iowa Food Assistance Program) SCRIPT

Asistencia para alimentos de Iowa (Iowa Food Assistance Program) SCRIPT Asistencia para alimentos de Iowa (Iowa Food Assistance Program) http://video.extension.iastate.edu/2011/12/14/asistencia para alimentos de iowa/ Six minute video in Spanish explaining what Food Assistance

Más detalles

UNIVERSIDAD DE MONTEVIDEO

UNIVERSIDAD DE MONTEVIDEO UNIVERSIDAD DE MONTEVIDEO Formulario de admisión para estudiantes internacionales Application form for International Students PHOTO Semestre 1 (marzo-julio) / Semester 1 (March-July) Año/ Year Semestre

Más detalles

CUESTIONARIO DISEÑADO PARA EVALUAR EL PRODUCTO DESCUBRE LAS PALMAS DE GC! QUE SERÁ ADMINISTRADO A TRAVÉS DE LA WEB CREADA PARA EL PRODUCTO.

CUESTIONARIO DISEÑADO PARA EVALUAR EL PRODUCTO DESCUBRE LAS PALMAS DE GC! QUE SERÁ ADMINISTRADO A TRAVÉS DE LA WEB CREADA PARA EL PRODUCTO. ANEXO E. CUESTIONARIO DISEÑADO PARA EVALUAR EL PRODUCTO DESCUBRE LAS PALMAS DE GC! QUE SERÁ ADMINISTRADO A TRAVÉS DE LA WEB CREADA PARA EL PRODUCTO. CUESTIONARIO: El proyecto Descubre Las Palmas de GC!

Más detalles

Identity and Statement of Educational Purpose (To Be Signed in the Presence of a Notary)

Identity and Statement of Educational Purpose (To Be Signed in the Presence of a Notary) Identity and Statement of Educational Purpose (To Be Signed in the Presence of a Notary) If the student is unable to appear in person at (Name of Postsecondary Educational Institution) to verify his or

Más detalles

Learning Masters. Fluent: States of Matter

Learning Masters. Fluent: States of Matter Learning Masters Fluent: States of Matter What I Learned List the three most important things you learned in this theme. Tell why you listed each one. 1. 2. 3. 22 States of Matter Learning Masters How

Más detalles

IN THE STATUTORY PROBATE COURT NO. OF EL PASO COUNTY, TEXAS PERSON OF: CAUSE NO.

IN THE STATUTORY PROBATE COURT NO. OF EL PASO COUNTY, TEXAS PERSON OF: CAUSE NO. IN THE STATUTORY PROBATE COURT NO. OF EL PASO COUNTY, TEXAS IN THE MATTER OF THE GUARDIANSHIP OF THE PERSON OF: CAUSE NO., AN INCAPACITATED PERSON GUARDIAN S REPORT ON THE CONDITION OF WARD (INFORME DEL

Más detalles

The ADE Direct Certification User Guide is a tool for authorized ADE and school district personnel to use in conjunction with the ADE Direct

The ADE Direct Certification User Guide is a tool for authorized ADE and school district personnel to use in conjunction with the ADE Direct The ADE Direct Certification User Guide is a tool for authorized ADE and school district personnel to use in conjunction with the ADE Direct Certification website. 1 This User Guide is a reference guide

Más detalles

Weatherization Assistance Program Application

Weatherization Assistance Program Application Community Development Department Weatherization Program: Our mission is to reduce energy cost for low-income families, particularly for the elderly, persons with disabilities, and children, through installation

Más detalles

NOTICE OF ERRATA MEDICARE Y USTED 2006 October 18, 2006

NOTICE OF ERRATA MEDICARE Y USTED 2006 October 18, 2006 CONTENTS 1) Notice of Errata 10/18/05 2) General Message for Partners 3) Action Plan for Spanish Handbook Error 4) Language for CMS Publication Mailing List 1 Where Does the Error Occur? NOTICE OF ERRATA

Más detalles

Employment Application FOR PART-TIME OR NON ACADEMIC STUDENT POSITIONS UP TO 25 HOURS PER WEEK OR LESS THAN 4 ½ MONTHS IN LENGTH

Employment Application FOR PART-TIME OR NON ACADEMIC STUDENT POSITIONS UP TO 25 HOURS PER WEEK OR LESS THAN 4 ½ MONTHS IN LENGTH NAME: (mbre) DATE (Fecha) EMPLOYMENT DESIRED You may select more than one position (Puesto deseado Puede seleccionar mas de uno) FOOD SERVICE (SERVICIO DE ALIMENTOS) Student Assistant (Asistente Estudiantil)

Más detalles

HEAD START MEDICATION ADMINISTRATION

HEAD START MEDICATION ADMINISTRATION HEAD START MEDICATION ADMINISTRATION Dear Parents/Guardians: It is the policy of Head Start to cooperate with each Head Start child's parent/guardian and his/her physician by administering and providing

Más detalles