Sherwood Valley Band of Pomo Indians

LIHEAP 2017 Payment Matrix

Applicant Name:______Date:______

Income Level Household Size

Under $23,963 / 5
Under $31,336 / 4
Under $38,709 / 3
Under $46,082 / 2
Under $53,455 / 1
Under $60,828 / 1
1 Person / 1
2 Person / 2
3 Person / 3
4 Person / 4
5 Person / 5
6 or more Persons / 6
Total Pts=
Total Pts=

Fuel Type Special Conditions

Electric/Natural Gas / 4
Wood / 4
Propane/Fuel Oil / 4
Kerosene/Pellets / 4
48 Hour Notice / 3
Disabled / 3
Elderly 55-59 yrs / 3
Elderly 60-65 yrs / 5
Elderly 65+ yrs / 7
Total Pts=
Total Pts=

Energy Burden

Energy Burden is calculated as follows: Energy Cost:______divided by Monthly Income= ______

15% 2 pts 30% 3 pts Total Pts=______

(Cost of Energy 15 % to 29% of Income) (Cost of Energy 30% or more of Income)

Benefit Level: Each Point Value= $15.00

(Maximum Benefit not to exceed $300.00)

4 pts=$60.00 / 10 pts=$150.00 / 16 pts=$240.00
5 pts=$75.00 / 11 pts=$165.00 / 17 pts=$255.00
6 pts=$90.00 / 12 pts=$180.00 / 18 pts=$270.00
7 pts=$105.00 / 13 pts=$195.00 / 19 pts=$285.00
8 pts= $120.00 / 14 pts=$210.00 / 20 pts=$300.00
9 pts=$135.00 / 15 pts=$225.00 / 20 + pts=$300.00 maximum