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23 - (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

Race (Required)*

Gender

Male

Female

Phone Number (Required)*

Mobile Number

Email Address (if applicable)

Do you rent or own your home?*

Rent

Own

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.)

First Name

Middle Initial (if applicable)

Last Name

Date of Birth

MM slash DD slash YYYY

Race

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

Race

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

Race

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

Race

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

Race

Gender

Male

Female

Relationship to You

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

Name

Middle Initial (if applicable)

Last Name

Date of Birth

MM slash DD slash YYYY

Race

Gender

Male

Female

Relationship to You

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

First Name

Middle Initial (if applicable)

Last Name

Date of Birth

MM slash DD slash YYYY

Race

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

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?

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.

Annual Household Income (Required)*

(5) Heat Provider Information

How do you heat your home? (Required)*

Natural Gas

Propane

Wood

No Heat Obligation

Fuel Oil

Electric Heat*

Coal

Other

Gas Provider Information (If Applicable)

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

Account Number

Account Owner

Hidden

Service Address

Hidden

City

Hidden

Zip Code

Propane / Fuel Oil Information (If Applicable)

Provider Name

Fuel % Remaining

Tank Size

Propane Metered?

Wood Fuel Information (If Applicable

Provider

Account Number

Fuel (Cords) Remaining

Do you have an indoor stove or an outdoor stove?

Indoor

Outdoor

(6) General Questions

What is your employment situation? (Required)*

A: Permanent employment/retirement

B: Temporary employment/seasonal/part-time

C: Unemployment

D: Disabled

What level of education do you have? (Required)*

A: Post-high school degree

B: High school diploma/GED

C: No high school diploma/GED

What is the size of your household? (Required)*

A: Single

B: Two to four people in household

C: Five or more people in household

Do you receive food assistance? (Required)*

A: No food assistance

B: Receiving food assistance

C: No access to food assistance

Do you have access to health care? (Required)*

A: All household members covered with affordable care

B: Some household members covered, some services affordable

C: No household members covered, no services affordable

Do you have transportation? (Required)*

A: Immediate, reliable, safe access to transportation

B: Limited/unreliable/unlicensed/uninsured access to transportation

C: No transportation

Do you have access to technology? (Required)*

A: Full technology access – personal and public means

B: Limited technology access – no computer/internet, limited understanding

C: No access to technology

If available, tell us what other resources you would be interested in learning about: (Required)*

Access to Technology

Housing Assistance

Rent/Mortgage Help

Employment

Disability Information

Self Sufficiency Services

Healthcare Access

Education

Case Management Services

Home Weatherization

Transportation

Food

Other

(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 authorize the assisting agency or provider to release my name and address to the local weatherizaton operator as part of the Weatherizaton Referral system. I authorize the department to release case and 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 authorize my energy company to release by phone, fax, email or their computer web site all available information about my account.*

YES

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

Affordable Payment Plan: I agree to the terms and conditions of the Affordable Payment Plan offered by my energy provider and have received a list of the terms and conditions plan. Please check ONLY ONE. (Required)*

YES - I agree

NO

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

YES

NO

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)*

Spouses Signature (If Applicable)

Enter today's date (Required)

(9) Budgeting Worksheet

INCOME

Income 1 - Frequency

Income 1 - Amount

Income 2 - Frequency

Income 2 - Amount

Additional Income - Frequency

Additional Income - Amount

HOUSING EXPENSES

Mortgage / Rent - Actual

Mortgage / Rent - Goal

Maintenance - Actual

Maintenance - Goal

HOA Dues- Actual

HOA Dues - Goal

Other - Actual

Other - Goal

TRANSPORTATION EXPENSES

Car Loan 1 - Actual

Car Loan 1 - Goal

Car Loan 2 - Actual

Car Loan 2- Goal

Gas Monthly - Actual

Gas Monthly - Goal

Repairs - Actual

Repairs - Goal

Other- Actual

Other - Goal

MEDICAL EXPENSES

Office Visits- Actual

Office Visits - Goal

Medications - Actual

Medications - Goal

Other - Actual

Other - Goal

PERSONAL EXPENSES

Child Care Expenses - Actual

Child Care Expenses - Goal

Child Support - Actual

Child Support - Goal

Alimony - Actual

Alimony - Goal

Other - Actual

Other - Goal

UTILITY EXPENSES

Natural Gas - Actual

Natural Gas - Goal

Electric - Actual

Electric - Goal

Water - Actual

Water - Goal

Sewer - Actual

Sewer - Goal

Trash / Recycling - Actual

Trash / Recycling - Goal

Home Phone - Actual

Home Phone - Goal

Internet - Actual

Internet - Goal

Cable / Satellite - Actual

Cable / Satellite - Goal

Other - Actual

Other - Goal

ENTERTAINMENT EXPENSES

Dining Out - Actual

Dining Out - Goal

Vacation Fund - Actual

Vacation Fund - Goal

HOUSEHOLD ITEM EXPENSES

Groceries - Actual

Groceries - Goal

Toiletries - Actual

Toiletries - Goal

Pets - Actual

Pets - Goal

INSURANCE EXPENSES

Homeowners - Actual

Homeowners - Goal

Renters - Actual

Renters - Goal

Health - Actual

Health - Goal

Auto - Actual

Auto - Goal

Life - Actual

Life - Goal

Disability - Actual

Disability - Goal

Long Term Care - Actual

Long Term Care - Goal

TAXES

Real Estate - Actual

Real Estate - Goal

Property Taxes - Actual

Property Taxes - Goal

DEBT REDUCTION

Credit Cards - Actual

Credit Cards- Goal

Personal Loans- Actual

Personal Loans - Goal

Student Loans - Actual

Student Loans - Goal

Savings - Actual

Savings - Goal

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