LIHEAP Application Document Checklist - CSD 43 (2022) and CSD 43-A Intake Addendum

Sep 19, 2026

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LIHEAP application checklist detailing required documents and how to complete submission forms. Applicants must provide an unexpired U.S. photo ID, Social Security number information, utility bills with current meter readings, and proof of household income for a 30-day period, supported by receipts and stubs. The packet also requires authorized forms (CSD 081 and related income certifications when applicable), rent or mortgage documentation, and water bill proof for LIHWAP support.

LanguageEnglish

CategoryForms

FormatPDF

Pages22

Reading Time8 min

AccessFree to download

LIHEAP Application Document Checklist

Required Completed Forms and Submission Rules

ID, Income, and Utility Documents

Rent, Water, and LIHWAP Notes

Common Types of Income

Document Checklist for LIHEAP Application You must submit all documents listed below along with the completed and signed forms CSD 43 (2022), CSD 081, and CSD 321. Use only blue and black pen on the forms. White out is unacceptable. If a correction needs to be made, cross out and initial the error. If a field or question is not applicable, write N/A. IF ANY PAGE IS LEFT BLANK, MISSING, OR INCOMPLETE, THE APPLICATION WILL NOT BE PROCESSED AND THE APPLICATION PACKET WILL BE RETURNED TO YOU 􀀀 Current Unexpired U.S. Government-issued Photo ID (applicant only) Note: If ID shows “Federal Limits Apply” and was issued prior to January 22, 2018, you must provide a copy of your U.S. Passport or birth certificate 􀀀 Social Security Number Note: for applicant only, written on application form. 􀀀 Current ELECTRIC and GAS Bill with Current Meter Readings. Bills must cover at least 22 service days Note: Both utility bills are required to process your application. You must send us all pages for both bills. If you are not responsible for one of these utilities, you are to provide proof such as your lease or landlord letter. 􀀀 Current Monthly Household Income. Must cover 30 days’ worth of income from application submission date (see “type of incomes” table below) . Note: Adults 18 years and older claiming zero income, self-employed household members, and members receiving monthly cash loans or gifts MUST complete form CSD43B Certification of Income and Expenses. Please include all income-related receipts, stubs, letters, etc. for the past 30 days to support your statements of income. 􀀀 Complete form CSD 081 Account Holder Authorization and Consent form. Note: This form is to ONLY be completed if either of the bills is not under your name. The account holder needs to complete and sign this form. If you attempt and are unable to collect signatures you are to complete our affidavit form found in this package. 􀀀 Current Mortgage Statement/Rent Receipt/Rental Agreement Note: if you are receiving subsidized housing, you are to provide us with a document from that program/ housing showing your rent portion. 􀀀 Current Water Bill with Meter Readings Note: We currently have funding to assist with water bills through the Low-Income Household Water Assistant Program (LIHWAP). If you need assistance with your water bill, you must also complete the CSD43-A intake addendum form. Your water company must be enrolled in the LIHWAP program. Call your utility provider to find out. | COMMON TYPES OF INCOME | | | --- | --- | | TANF/AFDC/CALFRESH Current verification of benefits | WORKERS COMPENSATION Current last 30 days check stubs | | WAGES/PAYSTUBS Last 4 weeks check stubs | PENSION Current check stubs or current award letters | | WORKERS COMPENSATION Current last 30 days check stubs | CHILD SUPPORT Current statement, detailed letter from payee | | STATE DISABILITY Last 4 weeks with award letter | FINANCIAL SUPPORT Detailed letter with full contact information | | FINANCIAL AID Current award letter with name | LOANS Current letter, loan contract | Return by mail or bring into our office: PACE HEAP 1055 Wilshire Blvd., Suite 900E, Los Angeles, CA 90017 Monday to Friday, 8:00am – 3:00pm Questions? Call us at (213) 989-3177 | Department of Community Services and Development
Energy Intake Form
CSD 43 (10/2022) | | | | | | | | | | | | | | | | Official Use Only: | | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | | | | | | | | | | | | | | | | | Priority Points | | | | | | | | | | | | | | | | | | | | A.C.C. | | | | Agency: PACE Intake Initials: Intake Date: | | | | | | | | | | | | | | | | Eligibility Cert Date | | | | First name | | | | | | Middle Initial | | | | | Last Name | | | | | | Date of Birth | | | | | | | | | | | | | | | | | | | | M

FAQs

What happens if pages are blank, missing, or incomplete in the LIHEAP packet?

The application will not be processed and the entire packet will be returned to the applicant.

What are the document rules for completing the forms?

Use only blue and black pen. White out is unacceptable; corrections must be crossed out and initialed. If a field does not apply, write N/A.

What income documentation is required for the LIHEAP application?

Monthly household income must cover 30 days from the submission date, supported by income-related receipts, stubs, and letters. Adults claiming zero income, self-employed members, and those receiving monthly cash loans or gifts must complete the appropriate income certification form.

Sep 19, 2026

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