RFP 450

ENERGY ASSISTANCEAPPLICATIONThe Office of Home Energy Programs will review your application for All MEAP and EUSP programs that apply . Note: An EUSP Benefit requires that you accept Budget Billing. Social Security Number NameMailing Address City, State, ZipPLEASE PRINT ALL INFORMATION Please complete the front and back of this form. Return completed form to the local OHEP office along with the following: Proof of Household ’s income received in the 30 days prior to the date you sign this application Proof of identification, of residence, and Social Security Number A current electric bill and /or a current gas bill (if you are responsible for paying heat) (If dif ferent from your mailing address or if you’ve moved)Cell phone W ork Friend RelativeHome Phone NumberOther Phone Number Your Street Address Apartment or Multi-Family Double, Row or Townhouse Single Family Home Mobile Home Homeowner Renter* Roomer/Boarder* Do you receive reduced rent through Help from HUD or Subsidized Housing (Section 8)? Yes No Do you Receive Utility Allowance Y es No (Check One) *If you rent:(Check One) RENTERS ONLY Is your heat included in the rent? Y es No OFFICE USE ONLY Landlord ’s Name/Apartment Complex: FED ID/SS# Landlord ’s Mailing Address: City: State: Zip: Landlord ’s Phone Number: ( )Date Returned Fill in all spaces below for ALL Household members ( List yourself First ): TOTAL # OF HOUSEHOLD MEMBERS IS T otal # of household members 18 years and over is ________ Please use the following choices for “Race”: 1. Black or African-American 2. White 3. Hispanic 4. Asian, Hawaiian or Pacific Islander 5. American Indian or Alaskan Native 6. Multi-Racial 7. Other FIRST & LAST NAMESOCIAL SECURITY NUMBERBIRTHDATE M/D/YrRELATIONSHIP TO APPLICANTSEX M/FRACE CODEAmerican (YES or NO)Disabled (Yes or No)List all Types of Income30-Day Gross Income 1. / / APPLICANT 2. / / 3. / / 4. / / 5. / / 6. / / If there are more persons living in the household, please list them on separate paper .1. 2. 3. (Turn Over) FIA/OHEP-14-003-S Attachment P 4. ELECTRIC UNIVERSAL SERVICE PROGRAM (EUSP) SSN NUMBER My electric company is The name on the account is Account Number I have a turn-off notice from this company: Yes No My Service is off now: Yes No CHECK ONE BOX BELOW FOR THE MAIN HEATING SOURCE OF YOUR HOME Electricity Utility Gas Propane Oil Kerosene Coal Wood/Pellets My Heat supplier or fuel Company is The name on the account is Account Number 7. Enrollment Options a. NO. I do not wish to be referred. 8. The applicant or proxy must sign this application before it can be processed.6. UNIVERSAL SERVICE PROTECTION PROGRAM (USPP) GAS ELECTRIC NONE Check for which service you would like to enroll in USPP. USPP helps customers prevent a shut off as long as they continue to pay the minimal monthly payment as required by their utility supplier. I understand that I do not have to participate in USPP to receive EUSP/MEAP benefits and no money will be paid to my account through USPP. If you have selected an alternative supplier, list the name here:I have a turn-off notice from this company: YES NO My service is turned off now: Yes NO a Applicant’s Signature Date COUNTY CENTER DATE RECEIVED INTAKE WORKER SIGNATURE DATE # IN HH TOTAL INCOME SUB/HUD YES NOCERTIFIER SIGNATURE DATE WORKER’S COMMENTS MEAP EUSP BILL ASSISTANCE EUSP ARREARAGEMEAP CRISIS CODE ANNUAL USAGE BENEFIT AMOUNT DENIAL CODEOFFICE USE ONLY: POVERTY LEVEL I declare that the information provided to Office of Home Energy Programs (OHEP) is true, correct, and complete. I understand that when this application is signed, permission is given: 1) for the OHEP and/or the Office of Inspector General (OIG) to check all household income, bank accounts, housing expenses, insurances and any other benefits; (2) for the other governmental/non-governmental agencies to give and/or receive information from OHEP needed to complete this application; and (3) for my gas/electric company or other agency giving a service/benefit to have information on this application given to them and/or received from them. “Unless you checked ‘NO’ on question #7-a, we will refer all necessary information to the DHCD’s energy efficiency programs. Your information may be shared with other organizations to confirm eligibility for other programs.” An appeal can filed to change this decision on this application or if help is not given in a reasonable time. The appeal must be filed within 15 days of the decision. The local agency will tell me how to file. Free legal advice is available through the Legal Aid Bureau by calling toll-free 1-800-999-8904. Maryland has a fraud Law. Punishment can occur for not telling the truth when applying for assistance to pay home energy costs. I understand that my application will be processed for all eligible benefits. I am NOT interested in receiving the following programs: ________ MEAP _______EUSP REASON: ______________________________________________________b.5. MARYLAND ENERGY ASSISTANCE PROGRAM (MEAP) Unless I check ‘NO’ below, I consent to be referred to the energy efficiency programs at the Maryland Department of Housing and Community Development (DHCD). These programs support the EmPOWER Maryland Energy Efficiency Act and can provide improvements and repairs to my home at no cost. I understand that, unless I select ‘NO’; my contact information will be referred to DHCD. I understand that I do not have to participate in DHCD’s energy efficiency programs to receive OHEP benefits. FIA/OHEP-14-003-S Attachment P