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Energy Security Plan Application

We are currently accepting a limit of 85 applications a day. If registration is closed, please try again the next day.

24 - (MEAP) Michigan Energy Security Program

"*" indicates required fields

(1) Applicant Information

Attach extra pages if you need to include additional members. List everyone who lives in your home, including adults and children temporarily absent due to illness or employment. People are considered members of your household if they sleep and keep their belongings in your home. Be sure to include the date of birth and citizenship status for each member.

First Name (Required)*

Middle Initial (if applicable)

Last Name (Required)*

Date of Birth*

MM slash DD slash YYYY

Gender

Male

Female

Hidden

Your relationship to other applicants. (Individual, Mother, Father, Guardian, Son, Daughter, etc.)

Phone Number (Required)*

Email Address (if applicable)

Applicants DHHS Case Number (If applicable)

Your Self-Sufficiency Coach's Name: (Agency Representative Signature)

Identification of Authorized Agency Representative

(2) Enter the names and relationship to you of any other persons living in the household.

PERSON 1 (Skip if no other people live with you.)

First Name

Middle Initial (if applicable)

Last Name

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Relationship to You

PERSON 2 (Skip if no other people live with you.)

First Name

Middle Initial (if applicable)

Last Name

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Relationship to You

PERSON 3 (Skip if no other people live with you.)

First Name

Middle Initial (if applicable)

Last Name

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Relationship to You

PERSON 4 (Skip if no other people live with you.)

First Name

Middle Initial (if applicable)

Last Name

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Relationship to You

PERSON 5 (Skip if no other people live with you.)

First Name

Middle Initial (if applicable)

Last Name

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Relationship to You

(3) Household Address (Service Address)

Address (Required)*

City (Required)*

State (Required)*

Zip Code (Required)*

County (Required)*

Mailing Address, if different than above

Address

City

State

Zip Code

County

Which best describes your current household situation? (Select only one of the following)

What is your current income source?*

Do you or someone in your household require medical equipment that increases your electric usage?

Does your household need assistance with an outstanding water bill?

(4) Home Heating Credit (HHC)

Have you applied for or received the HHC (Energy Draft) in the last six (6) months?*

YES

NO

Have you received energy assistance from another agency or through a provider-sponsored program since October 1st of last year?*

YES

NO

Annual Household Income

Please select the total combined Gross Annual (Household) Income from all sources of income that anyone in your household (all members of your household) received this year.

Gross Annual Household Income (Include income from ALL members of your household)*

(5) Heat Provider Information

How do you heat your home? (Required)*

Electric Heat

Natural Gas

Fuel Oil

Propane

Wood

Wood Pellets

No Heat Obligation

Other

Heat Provider Information

Provider

Account Number

Account Owner

Electric (non-heat) Provider Information (If Applicable)

*Electric heat sources include solar panels, boilers, radiators, or baseboard heating but DO NOT include space heaters

Provider Name

Account Owner

Electric Account Number

Additional Deliverable Fuel Information (If Applicable)

Propane / Fuel Oil % Remaining

Days Left

Stove Location

Tank Size

Metered

Provider Phone Number

(7) Applicant Agreements

Digital Signature Requirement

Please sign below after reading the following information, otherwise this application will be considered incomplete

As part of this MEAP agreement, I understand that I may be referred to or required to participate in additional services such as budgeting assistance, energy audits, or other programs that will my household pay energy bills and understand energy consumption. Participation in the activities outlined in this plan/agreement are required in order to receive any additional energy assistance benefits.*

YES - I AGREE

I authorize the assisting agency or provider to release my name and address to the local weatherization operation as part of the Weatherization Referral system. I authorize the department to release case and payment information to the Department of Health and Human Services, its affiliates and/or contracted agencies, for the purpose of research, study and evaluation of the Low Income Home Energy Assistance Program (LIHEAP) and the Michigan Energy Assistance Program (MEAP).*

YES - I AGREE

I authorize my energy company to release by phone, fax, email or their computer web site all available information about my account.*

YES - I AGREE

UNDER PENALTIES OF PERJURY, I SWEAR OR AFFIRM THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO ME. IF I AM A THIRD PARTY APPLYING ON BEHALF OF ANOTHER PERSON, I SWEAR THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO THE APPLICANT. TO THE BEST OF MY KNOWLEDGE, THE FACTS ARE TRUE AND COMPLETE.*

YES - I AGREE

Affordable Payment Plan:

My energy provider is one of the following: Consumers Energy, DTE Energy, Great Lakes Energy, SEMCO Energy, or UPPCO.*

YES

NO

If yes, please select one:

Select Option*

Terms of service: Consumers Energy DTE Energy SEMCO Energy UPPCO Great Lakes Energy

(8) Digital Signatures

Digital Signature of Applicant or Head of Household (Required)*

Enter today's date (Required)*

MM slash DD slash YYYY

Spouses Signature (If Applicable)

Enter today's date (Required)

MM slash DD slash YYYY

(9) Budgeting Worksheet

INCOME
Net Amount is the amount you receive after all deductions. Household Shopping Includes what you spend in food stamps (food, toiletries, pet supplies, household supplies, cleaning supplies, etc). Medical/Life Insurance premiums only if they are not deducted from your income

Income 1 - Net Amount

Income 2 - Net Amount

Food Stamps

HOUSING EXPENSES

Mortgage / Rent

Lot Rent

Property Taxes (Annual Divided by 12)

TRANSPORTATION EXPENSES

Car Payments

Gas/Rides

Car Insurance

MEDICAL EXPENSES