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.
Enter the names and relationship to you of any other persons living in the household.
Household Address (Service Address)
Mailing Address, if different than above
Home Heating Credit (HHC)
Have you applied for or received the HHC (Energy Draft) in the last six (6) months?
Have you received energy assistance from another agency or through a provider-sponsored program since October 1, 2018?
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.
Electric (non-heat) Provider Information
Heat Provider Information
*Electric heat sources include solar panels, boilers, radiators, or baseboard heating but DO NOT include space heaters
Propane/Fuel Oil Information (if applicable)
Wood Information (if applicable)
Digital Signature Requirement
Please sign below after reading the following information, otherwise this application will be considered incomplete
Affordable Payment Plan