Great Northern Services

310 Boles Street

Weed, CA 96094
(530) 938-4115
Fax (530) 938-1040
www.gnservices.org

Energy Assistance and Weatherization

2024 Online Application Introduction

Great Northern Services’ goal with our online application is to make it easier for clients to fill out and
submit the necessary paperwork. No one is required to apply online. If you would prefer a physical
application you may request one by calling (530) 938-4115 ext. 120.
Assistance is based on a State of California mandated system, not on a first-come first-serve basis.
Before applying you are asked to review the pre-application packet available for download on our
website. It includes the following information:
• Proof of income guidelines, how to document your energy usage, and program information
• Monthly Budget Planning Guide
• 2024 Fact Sheet-Income Guidelines
• WattSmart Energy Guide and an Energy Education Pamphlet
During the online application you will be asked to sign that you have received and reviewed these
materials.
At the end of the online application you will be asked to upload documentation of your income and
energy expenses. PDFs are the most reliable readable digital format to upload and there are free PDF
scanning apps available on most phones. If you must take a photo of physical documents, make sure
any image is clear and readable and captures the entire document.
Please review the pre-application packet to make sure you have the correct documents ready before
you begin.
If required items are missing or cannot be used we will contact you by email at the address you
provide. If we do not receive all the necessary documents we will not be able to provide assistance.
If you are requesting Weatherization as well as Energy Assistance you may be contacted with
additional forms to fill out.
We hope this online application makes it easier for some members of our community to go through
the application process. We understand that it is not for everyone and we are still committed to other
forms of outreach and intake. We offer application assistance by phone and we partner with
Community & Family Resource Centers to offer in-person assistance all around the county.

Great Northern Services’ Energy Assistance Department

[email protected]
Department of Community Services and Development Official Use Only:
Energy Intake Form Priority Points
CSD 43 (10/2022) A.C.C.
Agency: Intake Initials: Intake Date: Eligibility Cert Date
First name Middle Initial Last Name Date of Birth
MM/DD/YY
Jennifer L. Moreno June 21st 2024
SERVICE ADDRESS – Address where you live (this cannot be a P.O. Box)
Service Address Unit Number
316 Anderson Street N/A
Service City Service County Service State Service Zip Code
Yreka Siskiyou California 96097
Have you lived at this residence during each of the past 12 months? …………………………………………………………………….. ☐ Yes ☐ No
Is your service address the same as mailing address?................................................................................................... ☐ Yes ☐ No
Lease with option to buy exercized immediatly upon taking posseion of property as per the signed/noterized contract
Do you own or rent your home?..................................................................................................................................... ☐ Own ☐ Rent
Mailing Address Unit Number
316 Anderson Street
Mailing City Mailing County Mailing State Mailing Zip Code
Yreka Siskiyou California 96097
Social Security Number
(SSN): 6 5 5 5 8 0 3 4 9 Telephone Number ( 530 ) 643-9103
E-mail Address: [email protected]

PEOPLE LIVING IN HOUSEHOLD INCOME

Enter the total number of people
living in the household, 2 Enter the total number of people
who receive income 1
including yourself
Demographics: Enter the number of people in the Enter the total gross monthly income for all people living in
household who are: the household:
Ages 0 – 2 Years 0 TANF / CalWorks $ 732.00
Ages 3 - 5 years SSI / SSP $1.064.65
N/A
Ages 6 - 18 years 1 SSA / SSDI $
is also the disabled member
Ages 19 - 59 Paycheck(s) $
1
Ages 60 and older N/A Interest $
Disabled 1 Pension $
Native American Other $
Seasonal or Migrant Farmworker Total Monthly Income $ 1,972.65

HOUSEHOLD MEMBERS
ENTER THE INFORMATION BELOW FOR ALL HOUSEHOLD MEMBERS.
If you have more than 6 people in your household, please list the information on a separate piece of paper.

APPLICANT (HOUSEHOLD MEMBER 1)

First Name M.I. Last Name Relationship to Applicant
Self
Jennifer L. Moreno
Date of Birth: Feburary 12th 1981 Race: ☐ American Indian or Alaska Native ☐ Asian Hispanic/ Latino/Spanish?
Gender: ☐ Female ☐ Male ☐ Black or African American ☐ Yes ☐ No
☐ Other ☐ Native Hawaiian or Other Pacific Islander ☐ White ☐Unknown/Decline to
☐ Unknown/Decline to State ☐ Multi-Race ☐Other ☐Unknown/Decline to State State
Amount of Gross Monthly Income (before taxes): Source of Income:
$1,972.65 SSI, CalWorks and Child support

Page 1 of 3
 HOUSEHOLD MEMBER 2
First Name M.I. Last Name Relationship to Applicant

Jaydin R. Seaver Daughter

Date of Birth: March 21st 2010 Race: ☐ American Indian or Alaska Native ☐ Asian Hispanic/ Latino/Spanish?
Gender: ☐ Female ☐ Male ☐ Black or African American ☐ Yes ☐ No
☐ Other ☐ Native Hawaiian or Other Pacific Islander ☐ White ☐Unknown/Decline to
☐ Unknown/Decline to State ☐ Multi-Race ☐Other ☐Unknown/Decline to State State
Amount of Gross Monthly Income (before taxes): Source of Income:
N/A Student
HOUSEHOLD MEMBER 3
First Name M.I. Last Name Relationship to Applicant

Katherine F. Soto-Moreno Daughter

Date of Birth: July 17th 2005 Race: ☐ American Indian or Alaska Native ☐ Asian Hispanic/ Latino/Spanish?
Gender: ☐ Female ☐ Male ☐ Black or African American ☐ Yes ☐ No
☐ Other ☐ Native Hawaiian or Other Pacific Islander ☐ White ☐Unknown/Decline to
☐ Unknown/Decline to State ☐ Multi-Race ☐Other ☐Unknown/Decline to State State
Amount of Gross Monthly Income (before taxes): Source of Income:
$0.00 Student
HOUSEHOLD MEMBER 4
First Name M.I. Last Name Relationship to Applicant

N/A N/A N/A

Date of Birth: Race: ☐ American Indian or Alaska Native ☐ Asian Hispanic/ Latino/Spanish?
Gender: ☐ Female ☐ Male ☐ Black or African American ☐ Yes ☐ No
☐ Other ☐ Native Hawaiian or Other Pacific Islander ☐ White ☐Unknown/Decline to
☐ Unknown/Decline to State ☐ Multi-Race ☐Other ☐Unknown/Decline to State State
Amount of Gross Monthly Income (before taxes): Source of Income:
N/A N/A
HOUSEHOLD MEMBER 5
First Name M.I. Last Name Relationship to Applicant

N/A N/A N/A

Date of Birth: Race: ☐ American Indian or Alaska Native ☐ Asian Hispanic/ Latino/Spanish?
Gender: ☐ Female ☐ Male ☐ Black or African American ☐ Yes ☐ No
☐ Other ☐ Native Hawaiian or Other Pacific Islander ☐ White ☐Unknown/Decline to
☐ Unknown/Decline to State ☐ Multi-Race ☐Other ☐Unknown/Decline to State State
Amount of Gross Monthly Income (before taxes): Source of Income:
N/A N/A
HOUSEHOLD MEMBER 6
First Name M.I. Last Name Relationship to Applicant

N/A N/A N/A

Date of Birth: Race: ☐ American Indian or Alaska Native ☐ Asian Hispanic/ Latino/Spanish?
Gender: ☐ Female ☐ Male ☐ Black or African American ☐ Yes ☐ No
☐ Other ☐ Native Hawaiian or Other Pacific Islander ☐ White ☐Unknown/Decline to
☐ Unknown/Decline to State ☐ Multi-Race ☐Other ☐Unknown/Decline to State State
Amount of Gross Monthly Income (before taxes): Source of Income:
N/A N/A

Are you or someone in your household CURRENTLY receiving CalFresh (Food Stamps)? ☐ Yes ☐ No

Page 2 of 3
PAY BILL
To which energy bill (CHOOSE ONLY ONE) do you want the LIHEAP benefit to be applied? (Attach complete copy of most recent bill or receipt)
☐ Natural Gas ☐ Electricity ☐ Wood ☐ Propane ☐ Fuel Oil ☐ Kerosene ☐ Manufactured log ☐ Pellets ☐ Other Fuel
Enter the energy company and account number:
Pacific Power
Company Name: ___________________________________________ 46956674-001 2
Account #: _______________________________________
Is your utility service shut-off? ☐ Yes ☐ No
Do you have a past due notice? ☐ Yes ☐ No
Are your utilities included in rent or submetered? ☐ Yes ☐ No
Are your utilities all electric? ☐ Yes ☐ No
Is your Natural Gas Company the same as your Electric Company? ☐ 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).
0
Number of Days: ___________ ☐ N/A
ENERGY INFORMATION
The questions below are MANDATORY. Please check all energy sources used to heat your home.
A copy of all recent energy bills and/or receipts for any home energy cost must be provided.
NOTE: A copy of an electric bill must be included even if you do not use electricity to heat your home.
What is the main fuel used to HEAT your home? One main heating source MUST be checked.
☐ 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):
☐ Natural Gas ☐ Electricity ☐ Wood ☐ Propane ☐ Fuel Oil ☐ Kerosene ☐ Manufactured log ☐ Pellets ☐ Other Fuel ☐ N/A
Are you the account holder: Electric Bill ☐ Yes ☐ No Natural Gas Bill ☐ Yes ☐ No
The information on this application will be used to determine and verify my eligibility for assistance. By signing below, I give my consent (permission)
to CSD, its contractors, consultants, other federal or state agencies (CSD Partners) and to my utility company and its contractors, to share information
about my household’s utility account, energy usage and/or other information needed to provide services and benefits to me as described at the end
of the form. My consent shall be effective for the period beginning 24 months prior to, and continuing for 36 months after, the date signed below. 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 100805. If applicable, I hereby authorize installation of weatherization measures to my residence at no
cost to me. I declare, under penalty of perjury, that the information on this application is true, correct, and that the funds received will be used solely
for the purpose of paying my energy costs.

X June 21st 2024

* * * APPLICANT’S SIGNATURE * * * Date

AGENCY NAME: Community Services and Development (CSD). UNIT RESPONSIBLE FOR MAINTENANCE: Home Energy Assistance Program (HEAP).
AUTHORITY: Government Code Section 16367.6 (a) Names CSD as the agency responsible for managing HEAP. PURPOSE: The information you
provide will be used to decide if you are eligible for a LIHEAP payment and/or weatherization services. GIVING INFORMATION: This program is
voluntary. If you choose to apply for assistance, you must give all required information. OTHER INFORMATION: CSD uses statistical definitions from
the annual update of the Department of Health and Human Services' State Median Income, Federal Income Poverty Guidelines, to determine
program eligibility. During application processing, CSD's designated subcontractor may need to ask you for more information to decide your
eligibility for either or both programs. ACCESS: CSD's designated subcontractor will keep your completed application and other information, if used,
to determine your eligibility. You have the right to access all records holding information about you. CSD does not discriminate in the provision of
services on the basis of race, religious creed, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status,
sex, age, or sexual orientation.
APPLICANT: DO NOT FILL OUT THE INFORMATION BELOW. THIS SECTION IS FOR OFFICIAL USE ONLY.
Utility Assistance being provided under which program  ☐ HEAP ☐ Fast Track ☐ HEAP WPO ☐ ECIP WPO
Base Benefit $_______________ Supplement $_______________ Total Benefit $_______________
Total Energy Cost $________________________ Energy Burden _________________________
Energy Services Restored after disconnection: ☐ Yes ☐ No Disconnection of Energy Services prevented: ☐ Yes ☐ No
Home Referred for WX: ☐ Home Already Weatherized: ☐

Page 3 of 3
 Great Northern Services
310 Boles Street
Weed, CA 96094
(530) 938-4115
Fax (530) 938-1040
www.gnservices.org

Energy Assistance and Weatherization

Self-Certification of Disability

☐ Our household does not include any members with disabilities.

Primary Applicant Name:

Jennifer L. Moreno
Please list all household
members with a disability: Jennifer L. Moreno (self)

"I declare that I or one of my household members has a disability within the meaning of the
Rehabilitation Act of 1973."

Primary Applicant
Signature: Date: June 21st 2024

Home Address: 316 Anderson Street City: Yreka Zip: 96097

Under the Rehabilitation Act of 1973, individuals with disabilities are defined as persons with a
physical or mental impairment which substantially limits one or more major life activities.
People who have a history of, or who are regarded as having a physical or mental impairment
that substantially limits one or more major life activities, are also covered. Major life activities
include caring for one's self, walking, seeing, hearing, speaking, breathing, working, performing
manual tasks, and learning.

More information can be found at the following website:

https://www.hhs.gov/sites/default/files/ocr/civilrights/resources/factsheets/504.pdf
Department of Community Services and Development
Account Holder Authorization and Consent Form
CSD Form 081 (Rev. 12/17)
ACCOUNT HOLDER NAME(S) AND MAILING ADDRESS
Account Holder’s Full Name
Jennifer L. Moreno
Account Holder’s mailing address (Street) Unit Number (if any)

316 Anderson Street

(City) State Zip Code

Yreka California 96097

Is the utility service address the same as the account holder’s mailing address? Yes No

Full Name of Applicant for Benefits (from Form 43)

Jennifer L. Moreno
Utility Service Address (Street) Unit Number (if any)

316 Anderson Street

(City) State Zip Code
Yreka CA
96097
UTILITY INFORMATION
Please enter your utility company name and service account number below (you can find the account number on your bill). If
different companies provide your electricity and gas services, please enter the name and account number for both utilities.

46956674-001 2
Name of Utility Company Service Account Number

Pacific Power
Name of Utility Company (if you have a second Utility Company) Service Account Number

Vyve Broadband
AUTHORIZATION AND CONSENT
By signing this form, you (Account Holder) give your authorization and consent (permission) to CSD, its contractors,
consultants, other federal or state agencies (CSD Partners) and to your utility company and its contractors, to share
information about your property’s utility account, meter usage and energy consumption data, and other information as needed
for the period beginning 24 months prior to, and continuing for 36 months after, the date signed below. The information you
authorize us to obtain and share will be used for the purposes of evaluating home energy usage of program beneficiaries so
that CSD can: a) measure the effectiveness of the services we provide by determining how much your utility bills are reduced
and how much our services reduce carbon emissions (air pollution), and b) report these results to federal and state authorities
that fund and oversee energy assistance programs in California. CSD, its contractors, consultants, other federal or state
agencies and affiliated programs (CSD Partners), working cooperatively with your utility company and its contractors, use this
information to provide services that assist low-income families, such the applicant, to pay their home energy bills and mange
those energy needs for the purposes stated in this Authorization.
Signature of Account Holder Date Name of CSD Contractor/Partner Organization
Great Northern Services
June 21st 2023

REVOCATION OF AUTHORIZATION AND CONSENT

You agree that your consent shall remain in effect for 36 months from the date you sign this Authorization, unless otherwise
revoked by written notice mailed to: CSD Energy & Environmental Services Division, 2389 Gateway Oaks Drive, Suite 100,
Sacramento, CA 95833. Revocation will be effective upon receipt, but will not apply to any information shared while this
Authorization was valid.
APPLICABLE PROGRAMS
Some of the programs CSD oversees or partners with include:
- CSD Federal Low-Income Home Energy Assistance Program (LIHEAP)
- CSD Federal Department of Energy Weatherization Assistance Program (DOE WAP)
- State Low-Income Weatherization Program (LIWP)
- Department of Housing and Urban Development (HUD) Lead Hazard Control and Healthy Homes Program
- Utility Company Energy Savings Assistance (ESA) Program
- Utility Company California Alternate Rates for Energy (CARE) Program
Page 1 of 1
 Great Northern Services
310 Boles Street
Weed, CA 96094
(530) 938-4115
Fax (530) 938-1040
www.gnservices.org

Energy Assistance and Weatherization

Firewood/Pellet Usage Form

Name:
Jennifer L. Moreno
Signature: Date: June 21st 2023

Home Address: 316 Anderson Street City: Yreka Zip: 96097

☐ Our household does not use wood or pellets.

This form helps us evaluate your total energy cost. Please complete this form if you use any
firewood or pellets to heat your home.

Our household uses ________

5 cords/tons of firewood/pellets during the winter months.

☐We purchase firewood. ☐We cut our own wood.

We spend $______________
300.00 per (Your household energy expense will be
estimated using the average market value of a
cord/ton.
cord of wood)
(Generally, a cord of wood costs between $250-
$400/cord to have it delivered and stacked.)

A cord/ton of firewood/pellets last approximately __________

1 month(s).

Please read and initial each item if you are applying to receive firewood:

_________ If you are approved for firewood, do not sign the voucher until the firewood has
been delivered in the quantity and quality you ordered.

_________ A cord of wood is 4 feet high by 4 feet deep and 8 feet in length and tightly stacked

☐ My service address is in a remote location, is outside of city limits, and/or has additional
firewood delivery considerations:
______________________________________________________________________________
 Great Northern Services
310 Boles Street
Weed, CA 96094
(530) 938-4115
Fax (530) 938-1040
www.gnservices.org

Energy Assistance and Weatherization

Propane/Kerosene/Fuel Oil Usage Form

Name:
Jennifer L. Moreno
Signature: Date: June 21st 2024

Home Address: 316 Anderson Street City: Yreka Zip: 96097

☐Our household does not use any liquid fuels

This form helps us evaluate your total energy cost. Please complete this form if you use
propane, kerosene, or fuel oil in your home.

Which fuel do you use? ☐Propane ☐Kerosene ☐Fuel Oil ☐Other:__________

Please indicate which appliances use this fuel:

For GNS staff use, do not fill in

☐ Furnace or central heating system

__________
☐ Monitor / Toyotomi heater
__________
☐ Hot Water Heater
__________
☐ Cook Stove
__________
Other (please
☐
N/A
explain):_____________________ ___________
Total monthly
usage: ___________
Current price per
gallon: ___________
Total monthly
energy expense: ___________

N/A
Who is your fuel provider? ___________________________ Account #:_________________

We will need a current estimate from your fuel provider. Many local companies provide us with pricing on a
monthly basis but if your provider does not you may be asked to contact them to request a quote.
 Great Northern Services
310 Boles Street
Weed, CA 96094
(530) 938-4115
Fax (530) 938-1040
www.gnservices.org

COUNTY OF SISKIYOU
CALFRESH-FOOD/NUTRITIONAL ASSISTANCE
818 SOUTH MAIN STREET
YREKA, CA 96097
FAX# 530-841-2723

TO WHOM IT MAY CONCERN,

PLEASE FAX MY VERIFICATION OF BENEFITS TO GREAT NORTHERN SERVICES AT 530-938-1040.

Jennifer L. Moreno
_____________________________________________
PRINTED NAME

_____________________________________________ __________________
June 21st 2024

SIGNATURE DATE

#0123990
_____________________________
CASE #/SS #

Invigorate • Initiate • Improve

Access to Capital • Portfolio Management • Economic Development • Energy Assistance • Home Weatherization
Community Food • Community Services • HIV/AIDS Case Management • Community Development
CA Lic. # 629328
 Great Northern Services
310 Boles Street
Weed, CA 96094
(530) 938-4115
Fax (530) 938-1040
www.gnservices.org

Energy Assistance and Weatherization

Great Northern Services Application

ALL APPLICANTS must complete the first section!

Section 1
Name: Jennifer L. Moreno SSN: 558-65-03449

Home Address: 316 Anderson Street City: Yreka Zip: 96097

Cell phone: (530) 643-9103 Home phone:

☐ It’s ok to send me text messages about my application and additional services.

Email: [email protected]
☐ Please add me to the GNS email list
How did you hear about these services? ☐ Friends/Family ☐ Resource Center ☐ Social Media ☐ Other:

Is your residence a ☐ House ☐ Apartment ☐ Duplex ☐ Mobile Home ☐ Other

Do you ☐ own ☐ rent How much do you pay for rent/mortgage? $600.00
If you rent, do you receive a subsidy or voucher? ☐ No ☐ Yes, HUD or Section 8 ☐ Yes, Other
Has anyone in your home served in the US military? ☐ No ☐ Yes, active duty NAME(S):
☐ Yes, veteran NAME(S):

Would you like your home to be considered for weatherization services? ☐ Yes ☐ No

Section 2 (applicants requesting weatherization services must complete this section)

Has your home previously received weatherization services? ☐ No ☐ Yes, in ________________

Although there is no cost to property owners, they must grant permission and agree to the terms and conditions of the
Weatherization Program in order for a household to receive services. If you are not listed as the owner of record for the
property, please provide the contact information of the person who is or for their property management company.

Property Owner/Manager Name and Address: Emma S.Crittenden 4234 Saint Rose Way Yreka, California 96097
Property Owner pre 2015
Property Owner/Manager Phone and Fax and/or Email: (530) 643-0746
To receive weatherization services, Mobile/Manufactured Homes must have the appropriate registration and paperwork
filed with the HCD and/or Siskiyou County. If the dwelling is a MH please provide the Decal Number: _________________

Please note: we cannot provide weatherization services on dwellings that are listed for sale.
 Great Northern Services
310 Boles Street
Weed, CA 96094
(530) 938-4115
Fax (530) 938-1040
www.gnservices.org

Energy Assistance and Weatherization

Information and Education Acknowledgment Form
Sign and Return This Form

Established in 1981, LIHEAP is a federally funded program that helps low-income households
pay their energy bill. Assistance is in the form of a dual or single party warrant, or direct
payment to a utility provider on behalf of an eligible applicant. Eligibility is based on the
household’s total monthly income. Because of significant funding cuts, the federal government
requires that states target households with low-incomes and high energy costs, taking into
consideration households with elderly and disabled persons and children under six years of age.

An incomplete/incorrect application will take additional time to process or may be rejected.

Persons living in board-and-care facilities, nursing or convalescent homes, or in jail or prison are
not eligible for LIHEAP.

I have read and understand the following program guidelines and education pamphlets:
☐ the Energy Assistance and Weatherization program information sheet
☐ the WattSmart Energy Savings Guide
☐ the Energy Education Pamphlet
☐ the Resource Information Guide
☐ and reviewed and completed the Monthly Budget Planning Guide

Name: Jennifer L. Moreno

Signature: Date: June 21st 2024

(revised 12/22/2020)

Please sign, date and return with this packet

APPLICATIONS WILL NOT BE PROCESSED WITHOUT THIS FORM

Invigorate • Initiate • Improve

Access to Capital • Portfolio Management • Economic Development • Energy Assistance • Home Weatherization
Community Food • Community Services • HIV/AIDS Case Management • Community Development
CA Lic. # 629328
 Great Northern Services
310 Boles Street
Weed, CA 96094
(530) 938-4115
Fax (530) 938-1040
www.gnservices.org

Dwelling Details Form

required for all applicants

Please check all the boxes that apply to your home.

Wood / Pellet:
☐ Wood Stove ☐ Fireplace ☐ Pellet Stove ☐ Other: _________________ ☐ None
Propane:
☐ Central Heating System ☐ Fireplace ☐ Cook Stove ☐ Water Heater ☐ Other: ________________ ☐ None
Kerosene:
☐ Monitor Heater ☐ Central Heating System ☐ Water Heater ☐ Other: _________________ ☐ None
Furnace Oil / Fuel Oil/ Dyed Diesel:
☐ Furnace ☐ Water Heater ☐ Other: _________________ ☐ None
Electric:
☐ Central Air/Heat Pump ☐ Wall Heaters ☐ Baseboards ☐ Portable Space Heaters
☐ Cook Stove ☐ Water Heater ☐ Other: _________________ ☐ None
Other heating sources:
Electric Blankets When Needed
☐ Please describe: _____________________________________________________________________________

Weatherization applicants, what are your main concerns for your home?
I am quite concerned about the state of our windows and the quality of the insulation that helps keep the heat in and cold out during
during the winter months as well. The windows have many that are broken or missing panes of glass as well as the windows that are still
intact are very old and do help much with retaining the heat at night and the little bit that it does keep in just gets blown out through the
drafts that come through. The ceiling walls and floor insulation doesn't seem to be there at all or at least not doing what it was intended to
do. I know when the summer months come about the swamp cooler helps and that the cool air that it does help is pulled out but the draft
and bring in lots of dirt and dust from outside along with it. The water heater is concerning as well and has already blown breakers in
the main breaker box and has also needed my attention due to it leaking badly. Its also quite old and has never been much on energy
effiency at all. I do believe that some wind turbines on the roof would be helpful and help with the mainting tempatures is it was on a
thermostate to help regulate the tempatures in the roof crawl space. I do know that the primary concerns is mostly the windows, doors
and insulation of our home that i believe would help with our heating and cooling bills drasticlly. Due to my disablities I am not able to
go out as needed to cut firewood or kindling for use of the fireplace on a regular basis.
 310 Boles Street
Weed, CA 96094
(530) 938-4115
Fax (530) 938-1040
www.gnservices.org

Energy Assistance and Weatherization

Additional Documentation to Upload

Cal Fresh/ CalWORKS: If someone in your household receives CalFresh/CalWORKS benefits you need to
provide a current copy of their Verification of Benefits. If they do not have a current copy, complete the
included request form.

*NEW* Current recipients of CalFresh or CalWORKs benefits are categorically eligible for LIHEAP.
Those households self-report income for each household member of the Energy Intake Form.

Income Documentation (if no one in the household received CalFresh/CalWORKS): Upload copies of
all income verification for everyone in the household who is over the age of 18. All verification must
be dated within 30 days of submitting the application and it must reflect a full consecutive month.

Household members who are over 18 years of age and have no income need to complete and sign the
CERTIFICATION OF INCOME AND EXPENSES – CSD43B. The form can be found at gnservices.org/apply or
you can list their emails here and an online form will be sent to them to sign.
Katherine F. Soto-Moreno
Name: ___________________________________ [email protected]
Email: _________________________________
Name: ___________________________________ Email: _________________________________

Government Issued Photo ID: The primary applicant must provide proof of identification. See
instruction packet for acceptable forms.

Pacific Power Bill: Provide a copy of all pages of the household’s most recent electric bill. It cannot be a
“final or closing bill” and there needs to be a minimum of 22 elapsed days in the billing cycle.

NOTE: If you get to this point and do not see “Submit Signature” you can click on the red arrow to go
back and find required fields that haven’t been filled out.