BakerRipley

Housing and Energy Management

2023 Utility Assistance Application & Required Documents List

Dear Applicant,

Thank you for your interest in the 2023 Utility Assistance Program. Enclosed you will find an application along
with a list of the documents required with your application and instructions.

A signed, completed application and all the required documents are required to be submitted for your
application to be processed in a timely manner. If your application is incomplete or missing
documents, it will delay the review of your application and may result in your application being
denied. Please allow up to 8 weeks for determination of eligibility before calling to check your
application status.
Applications may be submitted by Mail or Fax:
(Only submit your application using one of the below methods)
BakerRipley - Utility Assistance Fax Number:
3838 Aberdeen Way OR (832) 295‐5834
Houston, TX 77025

Baker Ripley Utility Assistance 2023 Application Required Documents

1. BakerRipley Utility Assistance 2023 Application: Complete Pages 1-5: Answer all questions 1-17
2. Proof of Identity for all household members: submit proof of identity for all household members. Please
review Proof of Citizenship & Identity for Individuals document enclosed for a list of acceptable documents.
3. Proof of Citizenship or Residency for all household members: submit proof of citizenship for all household
members. Please review Proof of Citizenship & Identity for Individuals document enclosed for a list of
acceptable documents.
4. Income: submit proof of current income for all household members eighteen (18) years of age and older.
Include proof for consecutive pay periods reflecting 30 days prior to the signature date of the application.
(Examples include – Pay stubs, pension statements, unemployment insurance, disability, 2023 Social Security
award letters, all other monthly award benefit payments including SNAP, TANF, Veterans, Railroad, etc.)
5. Electric Bill: Submit front and back of current utility bill or disconnect notice.
6. Gas Bill: Submit front and back of current bill or disconnect notice.
7. Water Bill: Submit the front and back of current bill or disconnect notice.

Note: BakerRipley will determine eligibility and the financial assistance provided will be based on program requirements.
All documents mailed, dropped off or faxed are required to be in a legible format.
All electricity, gas and water vendors are required to have a current vendor agreement with BakerRipley.

Important information for Former Military Services Members: Women and men who served in any branch of the United States
Armed Forces, including Army, Navy, Marines, Coast Guard, Reserves or National Guard, may be eligible for additional benefits
and services. For more information please visit the Texas Veterans Portal at https://veterans.portal.texas.gov/.
BakerRipley | 3838 Aberdeen Way | Houston, TX 77025
Telephone: 713‐590‐2327 | Fax: 832‐295‐5834
 Proof of Citizenship & Identity for Individuals

When applying for utility assistance, the applicant is required to submit proof of citizenship or legal residency and identity for ALL HOUSEHOLD MEMBERS. Please
note the SAVE Applicant Certification Form is required to be submitted in addition to the documents below.
Proof of Citizenship, Legal Residency, and Identity – The documents below verifies both citizenship, legal residency, and identity. No additional documentation
is needed for a household member who submits any of the documents under Proof of CITIZENSHIP & IDENTITY below.
Proof of CITIZENSHIP & IDENTITY
Household members submit one of the following:  Permanent Resident Card (Form I-551) *
 Certificate of Naturalization (N-550 or N-570)* Please provide
 Valid, undamaged U. S. passport or passport card (can be expired)  Certificate of U. S. Citizenship (N-560 or N-561)*
 U. S. American Indian or Alaska Native tribal enrollment or OR front and back
 Refugee Travel Document (Form I-571)*
membership card with photo copies.
 Arrival/Departure Record (Form I-94)*
 Re-entry Permit (Form I-327)*
*All household members who provide this documentation will be entered into the Systematic Alien Verification for Entitlements (SAVE)

The applicant should provide the documents below if a household member does not have a U. S. Passport or any of the documents above.
*All household member who provide this documentation willProof of CITIZENSHIP
be entered into the Systematic Alien Verification for Entitlements (SAVE)
Household members submit one of the following: Household members submit two of the following:

 Birth certificate or birth record (including birth certificate cards) issued  Hospital Birth Certificate (often shows the baby’s footprints)
by the appropriate State Bureau of Vital Statistics or equivalent agency  U. S. Census record
from a U. S. state or local government, a U. S. territory, or the District  Early school records
OR
of Columbia  Doctor’s records of post-natal care
 Consular Report of Birth Abroad or Certificate of Birth / U. S.  Baptism Certificate
Department of State Certificate of Birth Abroad issued to U. S. citizens  Family Bible Record
born abroad ( Form FS-240, DS-1350, or FS-545)
Proof of IDENTITY
Household members submit one of the following: Household members submit two of the following:
 Texas Driver’s License or ID within 2 years of expiration  Birth certificate or birth record (including birth certificate
 Temporary Driver’s License with photo cards) issued by the appropriate State Bureau of Vital
 Out-of-State Driver’s License or ID with photo within 60 days of OR Statistics
expiration  Social Security Card
 Concealed Handgun License  Voter Registration Card
 U. S. Military or U. S. Military Dependent ID (unexpired)  Employee Work ID
 Matricula Consular (Mexican Consular ID)  Student ID/School Yearbook with identifiable photo
 Unexpired Foreign Passport  Selective Service (Draft) Card
 Texas Offender ID Card issued by TDCJ  Medicare or other health card
 Federal Inmate ID Card  W-2 or 1099
 School Records
 Immunization Records
 SAVE and US Citizenship Certification Form Instructions

This sheet can be used as a guide to complete the Systematic Alien Verification for Entitlements (SAVE) System Form.

Box 1  Household Member - All members of the household listed on the application must be listed on
the SAVE and US Citizenship Certification form.

Box 2  Citizen (Born or Naturalized) or U.S. National – The applicant must provide acceptable primary
or secondary forms of documentation for each household member. Reference the list of acceptable documentation
from the Proof of Citizenship and Identity for Individuals (included with the application).
Persons born in Puerto Rico, Guam, the US Virgin Islands, American Samoa, and Swains Island (or their
descendants) are U. S. citizens.
For household members who select Yes to this question with valid supporting documentation, no SAVE
verification is required.

Box 3  Qualified Alien - All household members answering “Yes” to this question must provide
documentation to be verified through SAVE. Reference the list of acceptable documentation from the Proof of
Citizenship and Identity for Individuals (included with the application).

Box 4  Documentation Provided - List the documentation provided for each member of the household
supporting their selected status. List document(s) used for Status AND Identification on this form.

The SAVE Certification Form is not valid without the applicant’s signature, AND the printed name and signature of
agency staff person who certifies that they verified all documents.

Household members who answer "No" to the "US Citizen (Born or Naturalized) or U.S. National" and the "Qualified
Alien" box, or who cannot provide supporting documentation are considered ineligible for utility assistance.

EXAMPLE
TEXAS DEPARTMENT OF HOUSING AND COMMUNITY AFFAIRS

Systematic Alien Verification for Entitlements (SAVE) System and US Citizenship/US National
Applicant Certification Form for WAP and CEAP

The program for which you are applying requires verification that you are a U.S. citizen, a non-citizen
national, or a legal resident of the United States. Documentation of your status is required. This agency
uses the Systematic Alien Verification for Entitlements (SAVE) System to verify the status of non-
citizens.

Box 1 Box 2 Box 3 Box 4

U.S. Citizen (Born or Qualified Alien Documentation Provided for:
Household Member Name Naturalized) or U.S. National (Yes/No) Status Identification
Joseph James
John Doe (example)
(example) Yes No Birth Certificate Drivers License

Mario Garcia
Jane Doe (example) No Yes Perma nent Res i dent Ca rd Permanent Resident Card

To add additional household members, use another copy of this form.

I AM AWARE THAT I AM SUBJECT TO PROSECUTION FOR PROVIDING FALSE OR FRAUDULENT INFORMATION.

(Sign Here) X John Doe 4/15/2023

Applicant's Signature Date

(please sign)
Signature of agency staff certifying they verified the above documents Print Staff Name Date
Please see next page to complete this form.
 BakerRipley
Housing & Energy Management
2023 Utility Assistance Application

APPLICANT INFORMATON
1. First Name Middle Name Last Name 2. County of Residency:

 Brazoria  Galveston  Harris

3. Residential Address

Apt #________________ City ____________________________ State_______________________ Zip Code______________

4. Mailing Address (leave blank if same as residential

address) Apt #________________ City ____________________________ State_______________________ Zip Code______________

5. Home Telephone: ( ) ________________-__________________ Cell Telephone: ( ) ________________-_____________________ Cell Phone Provider ______________________________

6. Would you like to receive status updates via (PLEASE CHECK THE APPROPRIATE BOX)  Email Text Email Address:______________________________________________________

7. Preferred Language  English  Spanish  Vietnamese  Chinese

HOUSEHOLD MEMBERS INFORMATION (List applicant first and all household members)
Applicant & 8B. Ethnicity 8C. Gender 8D. Date of Birth 8E. Military 8F. Migrant Seasonal 8G. Disability?
8A. Race Hispanic (H) or 8H. Receiving
Household Members Male, Female,
(MM/DD/YYYY) Status? Farm Worker?
Non-Hispanic (N) Other income?
First Name Last Name

1.  Active  Veteran  Yes No  Yes No  Yes No

2.  Active  Veteran  Yes No  Yes No  Yes No

3.  Active  Veteran  Yes No  Yes No  Yes No

4.  Active  Veteran  Yes No  Yes No  Yes No

5.  Active  Veteran  Yes No  Yes No  Yes No

6.  Active  Veteran  Yes No  Yes No  Yes No

7.  Active  Veteran  Yes No  Yes No  Yes No

8.  Active  Veteran  Yes No  Yes No  Yes No

FOR BAKERRIPLEY STAFF USE ONLY:

 New  HHCR  Re-Apply Case Number 23___________________________________ Application ID ________________________________

Reviewed & Entered by (Print) ________________________________________________ Signature___________________________________________________________

Page 1
 BakerRipley
Housing and Energy Management

9. Do you or anyone in the household currently receive the following? (PLEASE CHECK THE APPROPRIATE BOX)
 Supplemental Nutrition Assistance Program (SNAP)  Temporary Assistance for Needy Families (TANF)
If you do, please provide a current 2023 SNAP/TANF Award Letter.

10. Is the address listed on this application owned or rented by the applicant? 11. How much is the mortgage or rent?

Own Rent $______________._______ per Month  Half Month Two Weeks Week

12. Do you live in a? 13A. Are you interested in the Weatherization Program? Weatherization reduces air
leaking from your home, reduces your energy cost, and makes your home more
 House  Apartment  Mobile Home/ Trailer  Duplex  Townhouse
comfortable through the installation of energy saving materials.
Apartment or Landlord name _ (PLEASE CHECK APPROPRIATE BOX)  Yes No

Telephone Number ( ) - Alternate Number ( ) - 13B. Does your home’s heating and / or cooling system need service or repair?
(PLEASE CHECK APPROPRIATE BOX)  Yes No

14. How do you cool your home? 15. How do you heat your home?

 A/C Window Unit  Central A/C Unit Fans  Other  None  Gas Space Heater  Electric Space Heater Central Heat Unit  Stove-Oven  None

16. Does your name match the name on the utility bills? (CHECK ONE)  Yes No If no, explain why (ex. Deposit too high)

UTILITY INFORMATION
17. Which utilities do you have in your home? Electric Gas Propane Water

17C.Utility Provider
17A. Type of Bill 17B. Account Holder 17D. Account Number
(Name of Utility Company)
(Name on Bill)

Electric
Gas

Propane

Water

FOR BAKERRIPLEY STAFF USE ONLY: Case Number 23 ________________________

_________________________

Page 2
 BakerRipley
Housing and Energy Management

RELEASE OF CUSTOMER INFORMATION

As a Utility Assistance Program/Weatherization Assistance Program participant, I do hereby give permission to obtain and release personal information regarding my
case to other agencies as deemed necessary to further assist my household in accessing services and to funding sources for reporting purposes. Information
requested / released may include, but is not limited to, the following: 1) Services provided to or requested from the household by Utility Assistance
Program/Weatherization Assistance Program agency; 2) Status on utility accounts, payment and consumption histories; 3) Proof of income, residency, and
household members; 4) Employment; 5) Education and 6) Proof of identity and citizenship for all household members.
 The information provided is true and correct to the best of my knowledge and belief.
 My household income has been calculated to determine the household yearly income, according to pre-established agency procedures.
 I understand I may request a hearing to appeal a denial of eligibility, amount of assistance received, or a delay of service delivery.
 I authorize the Texas Department of Housing and Community Affairs and its contracted agency, BakerRipley, to solicit/verify information on my
utility and/or fuel bill, both past and future, to the extent the information is used only to provide data.
 I hereby authorize the Texas Department of Housing and Community Affairs and BakerRipley, to obtain online access to my utility account information for
the purpose of obtaining my 12-month billing history, 12-month payment history, and account balance to be used for the sole purpose of
determining my eligibility for benefits in the Utility Assistance Program/ W e a t h e r i z a t i o n A s s i s t a n c e P r o g r a m . I understand that the account
information obtained by BakerRipley may contain personal and/or personally-identifying information.
 I understand that BakerRipley will not use my information provided except as needed to review this application to determine eligibility.
 I am aware that I am subject to federal prosecution for providing false or fraudulent information.
 I understand that BakerRipley will use the U.S. Department of Homeland Security (DHS)/ Systematic Alien Verification for Entitlements (SAVE) to verify
status of non- U.S. born naturalized household members, citizens or permanent residents who provide the following documentation: Permanent Resident
Card, Certificate of Naturalization, Certificate of U.S. Citizenship, Refugee Travel Document, Arrival/Departure Record, or R e-entry Permit.

My signature indicates I have read the Release of Customer Information, Application Required Document List, received a copy of the
Customer Acknowledgement and agree to abide by the terms stated.

Applicant Name (Print) ______________________________________ ________________________________________

First Name Last Name

Applicant Signature ___________________________________ Impacted by COVID-19? YES _____ NO _____

Date Signed __________/__________/__2023___ FOR BAKERRIPLEY STAFF USE ONLY: Case Number 23 ______________

Page 3
 BakerRipley
Housing and Energy Management

Declaration of Income Statement

If you answered No to questions 8G or 8H complete this form (for anyone 18 years of age or older) in the household.
I am applying for utility assistance and have no documented proof of income for 1 or more household members 18 years of age or older due
to the reason(s) listed in the table below. All proof of income must be submitted along with this form.
Please complete steps 1 -3 in the chart below for all household members 18 years of age or older.
2. All household members 18 years of age or older must be listed. If a household member is 18 years of age or older and has
1. My household consists of _____ total NOT provided proof of income, check one of the reasons below or list the reason in “Other Reason.” 3. List previous
members. If proof of income was provided, indicate the type of income as Employer Wages or Award (s) and submit proof. 30 - day
The household members listed below are gross
For Paid in Cash list in “Other Reason” occupation and/or type of support received (ex. Family Support). income
18 years of age or older. (income received
Employer Wages before deductions)
List Household Member Name (First and Last Name) Age Award Paid in cash Unemployed with Other Reason
(Pay Stubs) Letter(s) No Income (Please explain)

    
    
    
    
    
    
TOTAL HOUSEHOLD GROSS AMOUNT $ _____________
$$_______________
I certify that the above information is true and correct to the best of my knowledge and belief. I understand that the information will be verified to an extent; and, that I am
subject to prosecution for providing false or fraudulent information.

APPLICANT ONLY:

Applicant Name (Printed) _____________________________________________ Applicant Signature ____________________________________

Date __________/__________/__2023____

FOR BAKERRIPLEY STAFF USE ONLY

Case Number 23____________________________________________ Application ID __________________________________________________

BakerRipley Representative (Print) ________________________________________ (Sign) _____________________________________________

Reviewed and Approved by (Manager) ________________________________________________________________________________________

Comments: ______________________________________________________________________________________________________________

Page 4
 TEXAS DEPARTMENT OF HOUSING AND COMMUNITY AFFAIRS
Systematic Alien Verification for Entitlements (SAVE) System and US Citizenship/
US National Applicant Certification Form for CEAP, DOE-WAP, LIHEAP-WAP Subrecipients, and SHTF, ESG, HHSP,
EH (political subdivision only)

The program for which you are applying requires verification that you are a U.S. citizen, a non-citizen national, or a legal resident of the United
States. Documentation of your status is required. This agency uses the Systematic Alien Verification for Entitlements (SAVE) System to verify the
status of non-citizens.

U.S. Citizen Office Use ONLY:

(Born or Naturalized) Documentation Provided for:
or U.S. National Qualified Alien
Household Member Name (Yes/No) (Yes/No) Citizenship/Qualified Alien Identification
1.

2.

3.

4.

5.

6.

7.

8.
To add additional household members, use another copy of this form.
I AM AWARE THAT I AM SUBJECT TO PROSECUTION FOR PROVIDING FALSE OR FRAUDULENT INFORMATION.

(Sign Here) X / /2023

Applicant's Signature Date

/ /2023
Signature of agency staff certifying they verified the above documents Print Staff Name Date
HSV Form updated 12/2019 Page 5
 CUSTOMER ACKNOWLEDGEMENT
PLEASE READ - KEEP THIS PAGE FOR YOUR RECORDS. DO NOT SUBMIT THIS PAGE WITH YOUR APPLICATION
 I understand the BakerRipley Utility Assistance Program is federally funded, and receiving assistance is based on income-eligibility, county of residence, citizenship or legal
residency status (verified by documentation submitted or verification through the Systematic Alien Verification for Entitlement), and available funding.
 I am required to apply each year for Utility Assistance Program. If I receive assistance it will not carry-over to the next calendar year.
 I understand the Utility Assistance Program funds are administered by BakerRipley, and that the Utility Assistance Program is not an emergency assistance program.
Application review for determination eligibility can take up to 8 weeks or longer after you submit your application. Applications are reviewed in the order received,
and submitting an application does NOT guarantee assistance.
 I understand that my household is required to meet the Federal Income Guidelines and live in Brazoria County, Galveston County or Harris County.
 I understand that if I do not submit all the documents as listed on the application required documentation list, my application is incomplete and there will be a delay in
reviewing my request for assistance.
 I understand that BakerRipley will not pledge assistance or make utility payments to the electricity, gas or water vendors until the application is complete and eligibility has been
determined.
 I understand that I am always responsible for paying my utility bill(s) before, during, and after the application and eligibility determination process.
 I am responsible for paying my utility vendor all remaining balances after the Utility Assistance Program makes a pledge/payment to my utility account. Non-payment of my
utility bill may result in the interruption of services.
 I understand that BakerRipley Utility Assistance Program provides assistance for electric, gas or water utility bills only. We do NOT provide assistance for rent/mortgage, trash,
sewer, cab le, internet, or telephone.
 I understand that BakerRipley will not pay any late fees, deposits, or reconnect charges and that I am responsible f or making payments for those fees and charges to my utility
vendor.
 If my application is approved, I will receive a Notice of Eligibility (NOE) providing my benefit amount(s).
 If my application is denied, I will receive a Notice of Denial (NOD) with the reasons indicated. The notice will include information on the appeal process.
 I understand that by requesting to receive status updates on my application via email and/or text, all messaging fees are my responsibility.
 I understand that for pledges and payments to be made, the utility vendor must have a vendor agreement on file with BakerRipley.
 I understand that it is my responsibility to notify BakerRipley of changes that could affect payment to my utility account, including but not limited to:
 Change in Utility Vendor
 Change of Account Number
 Change of Address, Telephone, or Email
 I understand to submit an inquiry or complaint, I can communicate my concern through the Utility Assistance Hotline at 713-590-2327. The concern can be communicated to
a Customer Service Representative and directed to the Utility Assistance Management Team. I can also submit an inquiry or complaint by email or mail. Correspondence
must be addressed as follows: Via Email to utilityassistance@bakerripley.org or via First-Class Mail – BakerRipley, Utility Assistance Program, 3838 Aberdeen Way, Houston,
TX 77025. I will be contacted within 2 business days from the date the concern is received by a member of the Utility Assistance Management Team.
 I understand that making a knowingly false statement or misrepresentation on this application may be subject to fines, imprisonment, or both.

BakerRipley – Utility Assistance

3838 Aberdeen Way Houston, TX 77025
Telephone: 713-590-2327 | Fax: 832-295-5834