Q7130g1. 1
I COMMISSIONERS' COURT AGENDA REQUEST
PLEASE FURNISH ONE ORIGINAL AND NINE COPIES OF THIS
REQUEST AND DOCUMENTS TO BE REVIEWED BY THE COURT.
MADE BY: Commissioner Williams
MEETING DATE: July 13, 2009
OFFICE: Precinct Two
TIME PREFERRED: 10:00 a.m.
SUBJECT: Presentation by Rose Jackson, AACOG Housing Manager, regarding
Weatherization Assistance Program's increased level of activities as a result of funding
from the American Recovery & Reinvestment Act (ARRA) over the next 2 years.
EXECUTIVE SESSION REQUESTED: (PLEASE STATE REASON)
NAME OF PERSON(S) ADDRESSING COURT: Commissioner Williams, Rose Jackson
ESTIMATED LENGTH OF PRESENTATION: 10 minutes
IF PERSONNEL MATTER -NAME OF EMPLOYEE:
Time for submitting this request for Court to assure that the matter is posted in accordance
with Title 5, Chapter 551 and 552, Government Code, is as follows:
Meeting scheduled for Mondays:
5:00 P.M. previous Tuesday.
THIS REQUEST RECEIVED BY:
THIS REQUEST RECEIVED ON:

All Agenda Requests will be screened by the County Judge's Office to determine if adequate
information has been prepared for the Court's formal consideration and action at time of Court
Meetings. Your cooperation will be appreciated and contribute towards you request being
addressed at the earliest opportunity. See Agenda Request Rules Adopted by Commissioners'
Court.
Alamo Area Council
Of Governments
AACOG WEATHERIZATION ASSISTANCE PROGRAM (AWAP)
WHAT IS AWAP?
The AACOG Weatherization Assistance Program (AWAP) is designed to help low-income
households, particularly the elderly (60 years and older) and persons with disabilities, to
overcome the high cost of energy, by installing energy conservation measures which help to
reduce your utility bills.
THE AWAP IS NOT A HOME REPAIR PROGRAM. AWAP DOES NOT DO ROOFING
PLUMBING, ELECTRICAL REPAIRS, OR HOUSE LEVELING AWAP IS NOT A WELFARE
PROGRAM. FUNDS ARE USED TO HELP CONSERVE OUR ENERGY RESOURCES
WHAT SERVICES DOES AWAP PROVIDE?
The following energy conservation measures are provided free of charge to eligible clients:
• Caulking and sealing cracks and holes in the house's structure.
• Weather stripping of doors and windows.
• Repairing and/or replacing windows and exterior doors.
• Insulating attics and walls.
• Incidental repairs to preserve and protect the weatherization materials installed.
WHAT DO I HAVE TO PAY?
NOTHING! The AWAP is free to people who are income eligible and accepted into the program.
However, funds are limited and not all people who are eligible will be served immediately. We
have a long waiting list.
AWAP services are available only once for the lifetime of the home.
DO I HAVE TO OWN MY HOME TO QUALIFY?
NO! Renters, as well as homeowners, are eligible to apply as long as your landlord gives
written permission for the work to be done.
WHERE DO 1 HAVE TO LIVE?
You must live in Atascosa, Bandera, Bexar, Comal, Frio, Gillespie, Guadalupe, Karnes, Kendall,
Kerr, Medina, or Wilson County to be eligible for the program.
REV 2/5/09
Income Eligiblity Guidelines*
Family Size	100%	125%	150%	200%
1	$10,830	$13,538	$16,245	$21,660
2	$14,570	$18,213	$21,855	$29,140
3	$18,310	$22,888	$27,465	$36,620
4	$22,050	$27,563	$33,075	$44,100
5	$25,790	$32,238	$38,685	$51,580
6	$29,530	$36,913	$44,295	$59,060
7	$33,270	$41,588	$49,905	$66,540
8	$37,010	$46,263	$55,515	$74,020
Amount to add
for each additional
Family Member
$3,740 $4,675 $5,610 $7,480
*Amounts are gross Annual Income
before taxes or deductions
r
Enclosed is your Weatherization Program application. It is important that you
complete all sections that pertain to your household.
Our federal guidelines require that we have verification of all income claimed for
anyone living in the household who is age 18 and over. The following checklist states
what is needed for an application to be complete:
_1. Provide roof of your household's gross income for the past thirty days from
the date you sign the application (ex: if you sign the application on July 4 then
you must provide income you received from June 4 to July 4). ~ an individual
18 and over in the household does not receive any income, the `Declaration of
Income Statement' (stating why they do not receive income) must be
completed, signed, and dated.
_2. Complete the Social Security Administration Consent for Release of Information
form to be used onl i an individual does not have their 2009 Social Security
award letter that verifies their Social Security,SSl, or monthly disability
benefits.
_.3. Complete all parts of the enclosed application, including signature and date on
page 3.
_4. Complete the `Home Information Survey' on the back of page 3.
_5. Sign and date the `Weatherization Utility Release Form'.
_6. Provide previously paid utility bills for electric and/or gas (other bills ex: for
water and telephone are not needed. )
_7. Mail/Fax complete application (front and back) to: AACOG, 8700 Tesoro Dr.,
Suite 700, San Antonio, Texas 78217-6228/fax (210) 225-5937
Incomplete applications will delay processing and, due to the limited funding, may
result in you not being provided services.
Upon receipt of the requested information, your application will be formally reviewed
to determine eligibility. You will be notified of such determination.
If you have questions, please call us at (210) 362-5282 or 1(800) 749-2010.
8700 Tesoro, Suite 700•San Antonio, Texas 78217.362-5200•Fax: (210) 225-5937•website: www.aacog.com•E-mail: mail@aacog.com
AACOG WEATHERIZATION ASSISTANCE PROGRAM -APPLICATION FOR WEATHERIZATION SERVICE
PROGRAMA DE CLIMATIZACION DEL HOGAR DE AACOG - SOLICITUD PARR SERVICIOS
A.
fame of Applicant or Head of Household Home Telephone
sombre del Solicitante O Responsable de la Casa Telefono de la Casa
Mailing Address Street/P.O. Box, City County Zip Work Telephone
Direccion postal Telefono del Trabajo
Residence Address - If Different County Zi
Direccion de Residencia - Si es diferente del ostal p
Condado Codi o Postal
Has this residence ever received services from the Weatherization program? Yes/Si No
Esta residencia ha recibido servicios del ro rama de climatizacion?
If "Yes", when ?/ Si marca "Si", Cuando?
GIVE THE FOLLOWING INFORMATION ABOUT EACH HOUSEHOLD MEMBER, INCLUDING YOURSELF:
ESCRIBA LOS NOMBRES DE TODOS LAS PERSONAS QUE VIVEN EN ESTA CASA TN('i T N>~~.mncr• n r rc~rnr~
B•
Name
Nombre	Date of
Birth
Fecha de	
Sex
Sexo	
Race *
Raza *	U.S. Citizen
Ciudadano
De Los E.U.A	
Handicapped
Inca acitado	
Social Security Number**
Numero de Seguro Social**
	Nacimiento			Yes/Si	No	Yes/Si	No	
								
								
								
								
								
								
								
								
-__- __-'_'_"...,...,»....... o..p... aw pale
Si necesita mas espasio, escriba al reverso de esta paging o en otro papel.
*This information is voluntary and is requested to ensure benefits are provided without regard to race, color or national
origin. It will not affect your eligibility or benefit level.
*Esta information es voluntaria y se solicita solo con el fin de asegurar que los beneficios se puedan ofrecer sin discrimination
de raza, color, u origen national. Esta information no afectara su eligibilidad ni cantidad de su beneficio.
**Although law does not require this information, it is necessary for correct computer processing.
**Aunque la ley no requiere esta information, es necesario para processar correctamente su solicitud por medios computarizado
GIVE THE FOLLOWING INFORMATION ABOUT HOUSEHOLD MEMBERS WHO WORK:
ESCRIBA LOS NOMBRE DE TODOS LAS PERSONAS VIVIENDO EN ESTA CASA QUE TRABAJAN:
C. JName of Persons Working Employer's Name, Address, and Telephone Number Total Monthly Income
Nombre de Personas que Trabajan Nombre, Direccion, y Telefono de sus Patrones Sueldo Total Mensual
-------------------------------------------------
For Office Use Only: -------------------------------------------------
Waiting List Referral: Kerrville Previous WAP
Page 1 Application
WEATHERIZATION ASSISTANCE PROGRAM -APPLICATION FOR WEATHERIZATION SERVICE
PROGRAMA DE CLIMATIZACION DEL HOGAR SOLICITUD PARA SERVICIOS
D If an household b
y mem ers receive the followmg types of unearned income or benefits, check the type of bene6
received. Where the space is provided, enter the case or account number and the a
t
i
moun
rece
ved.
Indique en to siguiente, los ingresos o beneficios que usted u otros miembros de su casa reciban. Incluya el
numero de identification de su casa o cuenta de a da la cantidad de ayuda.
DO NOT INCLUDE FOOD STAMPS AS INCOME/ NO ]NCLUY	E "ESTAMPILLAS DE COMIDA COMO INGRESOS.
Type of Assistance/Tipo de asistencia	Case Number	Monthly Amount
	Numero Del Caso	cantidad Mensual
AFDC/Asistencia AFDC		
SSI/Ingreso de Seguridad Suplemental		
Social Security/Seguro Social		
Veteran's BenefitsBeneficios de Veteranos		
Retirement Benefits/Beneficios de Retiro	
Military Allotments~Reparto de Sueldo Milita	
HUD Utility Supplement~Suplemento para las Utilidades de HUD	
Child Support/Sostenimiento para Ninos	
Unemployment Compensatiott'Compensacion de Desempleo	
Workman's Com ensatiodCom ensacion de Trabajadores	
Contributions/Re alos	
Other (s ecif) : Otro (es ecifi ue):	
Please check here if you are employed as a migrant worker or seasonal farmworker.
Favor de marcar si usted esta empleado como migrante o trabajador temporal de agricola?
E. What year was your home built? / En que ano fue la casa construido?
Do You Own or ~~Rent your residence?
Es
Dueno o se Renta su residencia?
If you ~ wn s1o to #1 If rented, go to #2
Si es dueno diri ese al #1 Si renta diri ese a #2
1 Type of Housing owned:
Tipo de casa propias:	2 Type of Housing Rented: MUST HAVE OWNER'S APPROVAL!
Tipo de caws rentadas:

Private house	TIENE QUE SER APROVADO POR EL DUENO!
~~Private Home C~A
t

Hogar	par
ment
Hogar Privado Apartamento
Mobile Home	C~Mobile Home R
t
d R

Casa Movil	en
e
oom
Casa Movil Cuarto Rentado
	~~Low rent federally subsidized Housin
T
S
	g
ype (
ection 8, etc)
Residencia con subsidio federal para la renta Tipo (Section 8, etc)
Type of energy used to heat household (Check one):
Tipo de ener~ia utilizada para calentar su hogar (marque una):
Natural Gas ~~ Electricity ~~Bottled Gas ~~Other (Specif
):
y
Gas Natural Electricidad Gas embotellado Otra (especifique):
Type of air conditioning used (check one):
Tipo de afire acondicionado utilizado (marque uno):
None ~ Central Unit Window Unit ~~Evaporative Cooler
Ninguno Unidad Central Unidad de ventana Enfriador evaporativo
Page 2 Application
WEATHERIZATION ASSISTANCE PROGRAM -APPLICATION FOR WEATHERIZATION SERVICE
PROGRAMA DE CLIMATIZACION DEL HOGAR SOLICITUD PARA SERVICIOS
WAP APPLICANT'S AUTHORIZATION, UNDERSTANDING AND AGREEMENT
My answers to all the previous questions and to the statements I have made are true and correct to the best of my
knowledge. I authorize the Texas Department of Housing and Community Affairs and its contracted agencies to
contact any source in order to solicit/verify information necessary for an eligibility determintion. I will also provide the
Texas Department of Housing and Community Affairs and its contracting agencies with any information necessary to
verify my eligibility.
If I am eligible for weaterization services, I give permission to allow work on the residence listed on this form. I will
cooperate fully with the state and federal personnel to obtain information from any source to verify statements I made.
I will cooperate fully with state or federal personnel in a quality control review.
I have been advised and understand that this application will be considered without regard to race, color, religion,
creed, national origin, sex, or political belief.
PENALTIES FOR FRAUD!
Whoever obtains or attempts to obtain weatherization services for which he is
not entitled, by means of willful false statements or other fraudulent means, may
be considered guilty of a criminal offense and, upon conviction, may be fined and
or imprisoned.
AUTORIZACION, ACUERDO, Y ENTENDIMIENTO DEL SOLICITANTE
Mis respuestas a todas las preguntas anteriores y las declaraciones que he hecho son verdaderas y correctas segun
mi leal saber, entender y creencia. Autorizo al "Texcas Department of Housing and Community Affairs" y a sus
agendas contratadas a comunicarse con culquier persona o agenda para verificar o solicitar information necesaria para
la determination de elegibilidad. Acepto responsabilidad de dar al Departamento cualquier information que se
necesite para verificar mi eligibilidad.
Si califico para servicios de Climatizacion de Hogar, doy permiso para que se Kagan reparaciones a la residencia
identificada en esta solicitud. Cooperare plenamente con personas del gobierno estatal o federal para obtener cualquier
information necesario para verificar las declaracioned que ha hecho, cual en to mismo se incluyen estudios tocante la
calidad del trabajo.
Me Kan avisado y entiendo que esta solicited sera considerada sin distincion de raza, color, religion, credo, origen
national, sexo, ni creencia politica.
CASTIGO POR FRAUDE!
Si alguna persona recibe servicios de Climatizacion del Hogar por medio de declaraciones falsas o intenta defraudar
por medio de estas declaraciones, se considerara culpable de una ofensa criminal y al ser convicta puede ser multada o
encarcelada.
BEFORE YOU SIGN, BE SURE EACH ANSWER IS COMPLETE AND ACCURATE
ASEGURESE, ANTES DE FIRMAR, QUE TODAS SUS RESPUESTAS ESTEN COMPLETAS Y CORRECTAS
Signature -Applicant
Date Signature -Spouse
Signature -Individual making application on
applicants behalf or caseworker who assisted
in completion of application
Firma del Solicitante -Firma de la persona que
hizo la solicited de parte del solicitante, o trabajador
social que ayudo hater la solicited
Date
Date
Signature-Witness (if signed with "X") Date
Firma -del Testigo (Si se firma con "X")
Page 3 Application
WEATHERIZATION PROGRAM
HOME INFORMATION SURVEY
NAME
1 TYPE OF HOUSE YOU LIVE IN :
WOOD FRAME HOUSE:
BRICK HOUSE:
rnvivC :
APARTMENT HOME: _
MOBILE HOME:
2 DOES YOUR ROOF LEAK? ~ ~ J 'YES ,a ~~ ~~~ ~ ~ 's+ NO~~~~~
DO YOUR CEILINGS HAVE LARGE HOLES OR CRACKS?
YES NO
DO YOUR CEILTNGS HAVE INSULATION?
YES NO
3 DOES YOUR HOME HAVE A GOOD FOUNDATION?~~ ~ ~~~ ' '~'~'-"-'~`
YES NO
ARE THERE ANY HOLES IN YOUR FLOORS?
YES N O
4 DO YOUR WALLS HAVE LARGE HOLES OR CRACKS? '" ~s' ~ ' '-`~'"-'~'
YES NO
DO YOUR WALLS HAVE INSULATION?
YES NO
5 HOW MANY WINDOWS DOES YOUR HOME HAVE? ~ ~ ~ ' '~'~'~'~'~'
WOOD ALUMINUM
ARE YOUR WINDOWS IN GOOD CONDITION?
YES NO
6 HOW MANY DOORS (TO THE OUTSIDE) DOES YOUR HOME HAVE? ~ ~ ~ ~ ~ "
ARE YOUR DOORS (TO THE OUTSIDE) IN GOOD CONDITION?
YES NO
7 WHAT DO YOU USE TO HEAT YOUR HOME IN THE WINTER? °~~s~ ~ '!' '~"
CENTRAL HEATING: HOW MANY?
SPACE HEATERS: HOW MANY?
WOOD STOVES HOW MANY?
8 WHAT DO YOU USE TO COOL YOUR HOME IN THE SUMMER? ~ ~ ~~~ '~'~'~"
WINDOW UNITS: HOW MANY?
CENTRAL AIR CONDITION:
9 IN YOUR OPINION WHAT DOES YOUR HOME NEED THE MOST?° °` ~ ° ~~~~°~'~'
10 WAS YOUR HOME BUILT BEFORE 1978? _s. ~~° °~° ~ °"~'~'~°""°"

.~'1
Alamo Area Coun 'I
ci
Oi= Governments
WEATHERIZATION ASSISTANCE PROGRAM FOR LOW INCOME PERSONS
COMPREHENSIVE ENERGY ASSISTANCE PROGRAM
CUSTOMER BILLING/CONSUMPTION RELEASE FORM
Number Street Apt./Lot #
City
Day
Evening
Zip Code
PLEASE ATTACH A PREVIOUSLY PAID GAS AND ELECTRIC BILL WITH YOUR APPLICATION
Agency : ALAMO AREA COUNCIL OF GOVERNMENTS
Name :
Last First MI
Address :
Telephone:
Electric Company:
Account Number:
(CPL Customers only)
CPL ESI ID #
(Entergy Customers only)
Entergy ESI ID #
(TXU Customers only)
TXU ESI ID #
Gas Company
Account Number:
Propane/Utner
Company
Account Number;
I authorize the Texas Department of Housing and Community Affairs and its contracted agency to solicit/verify
information on my energy billing and consumption histories, both past and future, to the extent the information is
used only to determine program eligibility and to provide data.
Signature (of name as it appears on utility bill) Date
FOR AGENCY USE ONLY ;
Subgrantee must record Weatherization Completion Date in box before mailing to
TDHCA.
Weatherization Completion Date
J DECLARATION OF INCOME STATEMENT
(DECLARACION DE INGRESOS)
I~ , do hereby declare on 20 that:
(Yo) (Applic:ant's Name/hombre del Solicitante) declaro que
^ I h~,~ve no documented proof of income due to the following situation
(ivc~ tengo prueba pars documentar mis ingresos por medio da tal rezones)
^ I ~,m applying for assistance from
(Yo deseo aplicar para asistencia con ;)
My household consists of number of persons and the following
household members, 18 years and older, have earned the following gross income
during the 30 day period prior to the date of application for assistance:
(En n~i hogar radican (Cuantas?) personas, y los siguentes miembros que tienen 18 anos de edad o
mas que han ganado dinero durante los pasados 30 dias antes de aplicar para asistencia. Indique el
noml~re y los ingresos ganados de cads miembro.)
Name: Gross Amount Earned:
Name: Gross Amount Earned:
Name: Gross Amount Earned:
^ My household's gross income, for all household members 18 years and older,
for the 30 day period prior to the date of application for assistance is $
(EI total de los ingresos de mi hogar, para los miembros que tienen 18 anos de edad o mas que
han ganado dinero durante los pasados 30 dias antes de aplicar por asistencia es (cuanto?).)
^ and my household's gross annualized income based on the 30 day period
prior to the date of application for assistance is $
(y el ingreso annual de mi hogar ha sido calculado para el ano, Begun los pasados 30 dias, antes
de aplicar para asistencia, Ilegan a (cuantos dolares?).)
I certify that the above information for the income of all household members 18 years
of ~~ge and older is true and correct to the best of my knowledge and belief. (Yo
cer+~ifico que la information proveida de los ingresos de los miembros de mi hogar que
tienen 18 anos o mas es verdadera y corrects segun mi saber y creencia.)
I understand that the information will be verified to the extent possible; and that I may
be: subject to prosecution for providing false or fraudulent information. (Comprendo
que la information sera verificada hasty donde sea possible y que puedo ser enjuiciado
p~~r haber proveido information falsa o fraudulenta.)
p pplicant Signature/Firms del Solocitante
street Address/Direction City/Ciudad County/Condado
Subrecipient Representative's Signature/Title
Reviewed & Approved (Ex.Dr, or Prog. Dir. Name & Title)
Date/Fecha
Zip/Codigo Postal
Date
Date
Social Security Administration
Consent for Release of Information
TO: Social Security Administration
Name
Date of Birth
Form Approved
OMB No. 0960-0566
Social Security Number
I authorize the Social Security Administration to release information or records about ine to:
NAME
Alamo Area Council of Governments (AACOG)
Housing Department: Attn. Christopher Villa
I want this information released because:
ADDRESS
8700 Tesoro Drive, Suite 700
San Antonio, Texas 78217
I am a plyin~ for the Weatherization Assistance Pro ram and these forms are needed to
determine my income eligibility for this program
(There may be a charge for releasing information.)
Please release the following information:

Social Security Number
Identifying information (includes date and place of birth, parents' names)
Monthly Social Security benefit amount
Monthly Supplemental Security Income payment amount
Information about benefits/payments I received from 01/2008 to resent
Information about my Medicare claim/coverage from to
(specify)
Medical records
Record(s) from my file (specify)
Other (specify)
I am the individual to whom the information/record applies or that person's parent (if a minor) or
legal guardian. I declare under penalty of perjury that I have examined all the information on this
form and it is true and correct to the best of my knowledge. I understand that anyone who
knowingly gives a false or misleading statement about a material fact in this information, or
causes someone else to do so, commits a crime and maybe sent to prison, or may face other
penalties, or both.
Signature:
(Show signatures, names, and addresses of two people if signed by mark.)
Date: Relationship:
Foam SSA-3288 (3-2005} EF (3-2005)



AACOG
8700 Tesoro Drive, Suite 700
San Antonio, TX 78217
www.aacog.com
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