test-form-meap – emPower™

(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

Phone Number (Required)*

Email Address (if applicable)

Enter Your MDHHS Case ID (Leave blank if one has not been assigned to you yet.)

Your Self-Sufficiency Coach's Name:

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.)

Middle Initial (if applicable)

Date of Birth

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

Middle Initial (if applicable)

Date of Birth

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

Middle Initial (if applicable)

Date of Birth

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

Middle Initial (if applicable)

Date of Birth

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

Middle Initial (if applicable)

Date of Birth

PERSON 6 (Skip if no other people live with you.)

Middle Initial (if applicable)

Date of Birth

PERSON 7 (Skip if no other people live with you.)

Middle Initial (if applicable)

Date of Birth

(3) Household Address (Service Address)

Zip Code (Required)*

Mailing Address, if different than above

What is your home situation?

(4) 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 1st of last year?

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.

Annual Household Income (Required)*

(5) Heat Provider Information

Gas Provider Information (If Applicable)

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

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

Hidden

Service Address

Propane / Fuel Oil Information (If Applicable)

Wood Fuel Information (If Applicable

Fuel (Cords) Remaining

(6) General Questions

(7) Applicant Agreements

Digital Signature Requirement

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

(MEAP) Michigan Energy Security Program

(1) Applicant Information

(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.)

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

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

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

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

PERSON 6 (Skip if no other people live with you.)

PERSON 7 (Skip if no other people live with you.)

(3) Household Address (Service Address)

Mailing Address, if different than above

(4) Home Heating Credit (HHC)

Annual Household Income

(5) Heat Provider Information

Gas Provider Information (If Applicable)

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

Propane / Fuel Oil Information (If Applicable)

Wood Fuel Information (If Applicable

(6) General Questions

(7) Applicant Agreements

Digital Signature Requirement

(8) Digital Signatures

(9) Budgeting Worksheet