Type of assistance you are requesting (circle all that apply): Energy Rental Medical/Dental Other

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1 Outreach Staff: Outreach Assistance Application A PROGRAM OF LA PUENTE 929 State Avenue P.O. Box 1235 Alamosa, CO Phone Fax outreach.lapuente@gmail.com Date applying: Type of assistance you are requesting (circle all that apply): Energy Rental Medical/Dental Other For energy assistance, you must provide a copy of your LEAP notification letter before La Puente can help you. Energy and rental assistance can each be used only once a year. General Information Applicant Name: ID#: (Last) (First) (MI) (Drivers License/Other ID) Account holder name: ID#: (Last) (First) (MI) (Drivers License/Other ID) Are You the Head of Household? Yes No If No, Name of Head of Household Current Marital Status (choose one): ( ) Married ( ) Domestic Partner ( ) Divorced ( ) Separated ( ) Widowed ( ) Single ( ) Common Law ( ) Don t Know ( ) Refused ( ) Other Relationship to Account Holder: Social Security Number: - - (used for HMIS database) Home Phone: Other Phone: Account Address: Address: Street: County: City:, Colorado Zip Code: Mailing Address (if different): Street: County: City:, Colorado Zip Code: How long have you lived at this address? Where did you stay before current address: house ( ) Apt ( ) other ( ) Have you ever been homeless: Yes ( ) No ( ) Demographic Information for Applicant Gender: Male ( ) Female ( ) Date of Birth: Age: Employed: Yes ( ) No ( ) Disabled: Yes ( ) No ( ) Migrant: Yes ( ) No ( ) Disabling Condition: Education Level: 0-8 th 9-12 Non-Graduate High School Grad/GED 12+Some College 2/4 year Degree Ethnicity (Optional): Non-Hispanic/Non-Latino Hispanic/Latino Don t Know Refused

2 Race (Optional): White Black or African American American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander Other Don t Know Refused Are you (Circle all that apply): A Victim of Domestic Violence A Person with HIV/AIDS Severely Mentally Ill Other Disability Elderly Veteran Chronic Substance Abuse Has anyone in your household (that will be served by this utility or rental assistance), served in the military in any capacity? Yes No N/A If yes, who?. Which military branch? When? Do you have Ongoing Medical Conditions?: Yes No If yes, what? Do you have Health Insurance?: Yes No If yes, what type? Do you have any unmet health needs? Yes No If yes, what? Income Information: Gross Monthly Cash Income: $ Source of Income (circle all that apply): No Income SSI SSDI Social Security Pension General Asst. Aid to Blind Aid to Needy Disabled Old Age Pension Unemployment Ins. Employment Other TANF Name of worker assigned to your TANF case: Other Assistance Food Stamps? $ WIC? Yes No Household Type (circle type that is most appropriate for your situation): Two Adults Single Parent-Female Single Parent-Male Two Parent Single Person Please list everyone besides yourself living in your household: Name date of birth age ethnicity relationship to you Social security (last four digits) Total # in Family: # Male # Female

3 Budget Information: Net (after-tax) Monthly Household Income:------$ Monthly Expenses: Rent / Mortgage $ Gas/ Electricity $ Water $ Cable $ Trash & Sewer $ Telephone $ Insurance(s) $ Loan Payment(s) $ Groceries $ Household Supply $ Daycare $ Prescription(s) $ Personal spending $ Transportation $ Other $ TOTAL EXPENSES: Income $ - Expenses $ = $ FOR STAFF USE ONLY: Poverty Percentage: Go over Energy Resource Guide: Housing Information

4 Type of Housing (circle one that applies): Apartment House Mobile Home Boarding House Duplex Townhouse/Condo Other/Not Reported Do you: Square footage of your home: sq. feet (if don t know enter 0) Rent or Own Has your house been weatherized in last 10 years by certified weatherization program?: Yes No Total number of rooms in your home including bedrooms, kitchen, living room, bathroom, etc.: Fuel Type (circle all that apply): Fuel Oil: gal. tank Diesel: gal. tank Propane: gal. tank Firewood Natural Gas Gas/Electric Fuel Pellets Coal Electricity Other Indicate the type of fuel are you applying for: Who is your utility Provider? Have you applied for LEAP? Yes No If yes, when? Please describe the previous La Puente Outreach assistance received by you or any member of your household: Date of Assistance: Type of Assistance: Have you or any member of your household ever been assisted by another La Puente Program? Yes No If yes, name of Program Date of Assistance: ****Please complete the information below only if you are requesting assistance for rent or energy**** Please circle all that best explains your situation leading to problems paying your bill: Job loss / Lay-off (when?: ) Illness/Injury/Disability Sub Prime Mortgage Landlord Conflict Utility Cost Increase Legal Trouble Other: If approved for assistance La Puente Outreach Services may only be able to pay for a portion of your past due amount. How do you plan to pay the remaining balance? In the coming months, how will you keep from becoming past due again? Please identify any foreseeable barriers that might prevent you from making these payments.

5 Name of Landlord/Mortgage Bank: Contact Name: Phone: Fax #: *attach copy of mortgage statement to this form Before making an appointment we require that you make personal contact with your landlord/mortgage bank. Below, Please summarize the results of this conversation: How many months are you behind in rent? How much of that is rent?: How much do you owe?: How much of that is late fees?: How many bedrooms?: Standard Housing Check List The housing in which I live: Is in good condition and is not falling apart. True / False Has indoor plumbing. True / False Has a usable flush toilet inside the unit for my family use only True / False Has a usable bathtub or shower inside the unit for my family use only True / False Has electricity, and does not have unsafe electrical service. True / False Has a safe and adequate source of light. True / False Has a kitchen. True / False Is safe for living and has not been condemned by an agency or government office. True / False

6 CONFIDENTIALITY AGREEMENT The following is a confidentiality agreement to allow La Puente Outreach Service Center / La Puente Outreach Staff to share with other agencies, including but not limited to utility companies, whatever essential information about your case that might be helpful in getting resources to meet your personal needs. Any information will be given without discrimination and with discretion for your rights. I hereby give my permission to any duly authorized representative of La Puente Outreach Service Center / La Puente Outreach Staff to supply information to or request information from other persons, agencies or institutions pertaining to me or my family. I release Outreach Service Center / La Puente Outreach Staff of any and all liability for supplying or requesting such information. This shall be in effect until I state in writing that it is no longer valid. Client Name Intake Staff Signature of Client Agency Staff Date *All necessary paperwork for the assistance you are requesting must accompany this application. This application will not be processed if incomplete. Please read the above statement, and initial here in agreement:

7 CONFIDENTIALITY AGREEMENT AND CONSENT TO DISCLOSE CUSTOMER DATA This Confidentiality Agreement and Consent Contains: Part 1: Confidentiality Agreement to allow the following Agency: Agency Name: La Puente Outreach Phone: Contact Name: John Reesor, Tara Bay, Andrea Preciado, Lindsay Toman Mailing Address: P.O. Box 1235, Alamosa, CO Colorado PUC E-Filings System Physical Address: Same 929 State Street, Alamosa, CO and the Agency s Staff and Energy Outreach Colorado 1 (EOC) to share with other agencies, including but not limited to utility companies, whatever essential information about your case that might be helpful in getting resources to meet your personal needs. Any information will be given without discrimination and with discretion for your rights; and Part 2: Consent to authorize your utility service provider to disclose the following information to the Agency, Agency Staff and Energy Outreach Colorado: Your utility account payment history and other account details, such as utility charges, payment history, past due amounts, pending deposits, current shut-off due dates or disconnection, current life support status, payment arrangements, and history of energy assistance payments. Your general energy usage for up to twenty-four months (at no greater level of detail than monthly totals), which is customer-specific information that is collected from your Electric Natural Gas utility meter by your utility service provider. The Agency, Agency Staff and Energy Outreach Colorado will use this information to help determine your eligibility for and assist you in applying to participate in energy assistance programs. If you authorize the disclosure, it will start on the date you sign this Consent. You have a right to receive a copy of this form from EOC. Please note that: You are not required to authorize your utility service provider to disclose your customer data. Your decision not to authorize the disclosure will not affect your utility services. 1 EOC is a Colorado nonprofit corporation established by the Colorado legislature to collect and disburse low-income energy assistance funds in accordance with the Low-Income Energy Assistance Act, Colo. Rev. Stat., , et seq.,

8 Your utility service provider may not disclose your customer data except (1) if you authorize the disclosure, (2) to contracted agents that perform services on behalf of the utility, or (3) as otherwise permitted or required by laws or regulations. Your utility service provider will have no control over the data disclosed pursuant to this Consent, and will not be responsible for monitoring or taking any steps to ensure that the Agency, Agency Staff or Energy Outreach Colorado maintain the confidentiality of the data or use the data as authorized by you. By signing this Confidentiality Agreement and Consent, you acknowledge and agree that: You give permission to any duly authorized representative of the Agency and Energy Outreach Colorado to supply information to or request information from other persons, agencies or institutions pertaining to you or your family. You release the Agency and the Energy Outreach Colorado of any and all liability for supplying or requesting such information. You are the customer of record for the utility services account specified below, and you authorize your utility service provider to disclose your customer data as specified in Part 2 above. You may terminate this Confidentiality Agreement and Consent to Disclose Customer Data at any time by sending a written request with your name and service address to your utility service provider at and the Agency at the address specified above. If you do not terminate this Confidentiality Agreement and Consent to Disclose Customer Data, this will automatically terminate when your participation in the relevant energy assistance program is terminated. CLIENT S UTILITY CUSTOMER ACCOUNT NUMBER SERVICE ADDRESS CLIENT SIGNATURE CLIENT PRINTED NAME DATE SIGNED AGENCY STAFF SIGNATURE AGENCY CASE NUMBER DATE SIGNED

9 10. CONSENT TO DISCLOSE CUSTOMER DATA The Colorado LEAP office Lincoln Street, Suite 1007 Denver, CO Heat Help Line: (866) leapprogram@state.co.us (please refer to the LEAP website for a list of affiliated county LEAP offices that may provide you with assistance: is requesting that you authorize your utility service provider to disclose the following information to the LEAP office: Your utility account payment history and other account details, such as utility charges, payment history, past due amounts, pending deposits, current shut-off due dates or disconnection, current life support status, payment arrangements, and history of energy assistance payments. Your general energy usage data for up to twenty-four months (at no greater level of detail than monthly totals), which is customer-specific information that is collected from your Electric Natural Gas utility meter by your utility service provider. The LEAP office will use this information to help determine your eligibility for and assist you in applying to participate in energy assistance programs. If you authorize the disclosure, it will start on the date you sign this application and end when you terminate your participation in the relevant energy assistance program. You have a right to receive a copy of this form from LEAP. Please note that: You are not required to authorize your utility service provider to disclose your customer data. Your decision not to authorize the disclosure will not affect your utility services. Your utility service provider may not disclose your customer data except (1) if you authorize the disclosure, (2) to contracted agents that perform services on behalf of the utility, or (3) as otherwise permitted or required by laws or regulations. Your utility service provider will have no control over the data disclosed pursuant to this consent, and will not be responsible for monitoring or taking any steps to ensure that the LEAP office maintains the confidentiality of the data or uses the data as authorized by you. Pursuant to section , C.R.S., LEAP will not disclose any private applicant information except for the purpose of administering public assistance as defined by State and Federal laws and regulations. 2 LEAP is the Colorado Low-Income Energy Assistance Program administered by the Colorado Department of Human Services and LEAP s affiliates.

10 11. SIGNATURE AND CONSENT By signing below I understand, I acknowledge and agree that: 1. If I am contacted by weatherization, my refusal to permit weatherization of my home may result in denial of LEAP benefits. 2. My Social Security Number will be used to request and exchange information with other agencies as part of the eligibility verification process. 3. The Colorado Department of Human Services (CDHS) may use my Social Security Number to get wage data, amount of unearned income, child support case and payment disbursement records, interest income, Social Security benefits, pensions, railroad retirement, or veteran's benefits. As part of the eligibility verification process, the CDHS has my permission to contact other agencies on my behalf to establish eligibility. 4. I am the customer of record, the customer s authorized agent, or an authorized third party for the utility service account identified in this application, and I authorize my utility service provider to disclose my customer data as specified in Section 10 of this application. 5. You may terminate your consent to the disclosure of your customer data by your utility service provider to the LEAP office at any time by sending a written request with your name and service address to your utility service provider identified in Section 6. I declare that the information given by me in this application is true and correct. I understand the penalty for providing false information shall be no more than a $15,000 fine, or not more than 5 years imprisonment, or both.