EnergizeCT EnergizeCT Income Eligible Application Fields marked (*) are required. Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Income Qualifications: Examples of Income Information: Most recent weekly or biweekly pay stub Alimony, child support, pension/retirement check stub Recent quarterly self-employment tax statement(s) Proof of Social Security or Supplemental Security Income (SSI) benefit award letter Current unemployment letter Zero Income Affidavit for anyone age 18 or older with no income Submitting an application does not automatically qualify you for a Home Energy Solutions – Income Eligible assessment. Final qualification will be determined by the utilities upon application submission by New England Smart Energy. Do you qualify? *YesNoWe’re sorry, you must qualify to proceed with this application. Click here to return to the homepage Section 1: Property Information (1-4 Units)Property Address *Address Line 1Address Line 2City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone *Number of Apartments in the Property *Type of Dwelling *Single Family HomeApartmentCondominiumSection 2: Applicant and Energy InformationFirst Name *Last Name *Phone *Email *Applicant Is the (Check One) *Property OwnerRenter/TenantPrimary Heating Fuel Type (Check One, if Known)ElectricNatural GasOilPropaneProperty Owner (Landlord) Name *Natural Gas Utility (Check One)CNGEversourceSCGProperty Owner (Landlord) Address *Address Line 1City— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeElectric Utility (Check One) *EversourceUIOtherOther: *Gas Account Is Listed UnderApplicantOtherOther Account Holder's NameElectric Account Is Listed Under *ApplicantOtherOther Account Holder's Name *Electric Account Number *Gas Account NumberSection 3: Applicant Qualification InformationApplicant Qualification Options: There are four options for an applicant to qualify for Home Energy Solutions – Income Eligible. Please check the appropriate box and provide the required information.Option A: If applicant is enrolled in one of the following utility programs. Please check the box that applies. No other information is required. EversourceElectric Discount RateMatching Payment ProgramCNG, SCG, UI:Low-Income Discount RateBill Forgiveness ProgramMatching Payment ProgramOption B: If applicant has one of the following (please check the box and provide a copy): Option BEBT Award Letter for Supplement Income RecipientsEnergy Assistance Award LetterSection 8 Housing Choice Voucher Unit Number of Option C: If applicant meets the household maximum annual income requirements. How many people live in your household?How many people live in your household who are age 18 or older?Annual income of ALL household members age 18 and olderOption D: If Option D is selected, the property owner must complete the following table to include addresses for all units to be served. Option DProperty that is a multifamily building with two to four units and at least 50 percent of the other tenants of the property qualify for Home Energy Solutions – Income Eligible services.First Unit Address (Include Unit/Apt Number & Floor Number If Applicable)First Unit Tenant/Resident NameFirst Unit Primary Heating FuelSecond Unit Address (Include Unit/Apt Number & Floor Number If Applicable)Second Unit Tenant/Resident NameSecond Unit Primary Heating FuelThird Unit Address (Include Unit/Apt Number & Floor Number If Applicable)Third Unit Tenant/Resident NameThird Unit Primary Heating FuelFourth Unit Address (Include Unit/Apt Number & Floor Number If Applicable)Fourth Unit Tenant/Resident NameFourth Unit Primary Heating FuelReferring Company (if applicable)Section 4: AuthorizationI am the applicant who has completed this application and request Home Energy Solutions – Income Eligible services for the property listed in Section 1. I understand, if qualified, the initial visit will be provided at no cost. I authorize Eversource and CNG, SCG and UI and their authorized contractors and agents, to enter my property to perform the initial visit, provide Home Energy Solutions – Income Eligible services, and conduct verification to confirm proper install. I understand that if the incomequalifying information I have supplied is not correct, I may be charged for the energy efficiency program services I received through the Home Energy Solutions – Income Eligible program.Signature * Clear Signature Date *Submit
