Energize CT

Home Energy Solutions℠ - Income Eligible Application

ENERGIZE CONNECTICUT℠

Thank you for your interest in Home Energy Solutions – Income Eligible. The Connecticut Light and Power Company and Yankee Gas Service Company, each doing business as Eversource Energy (Eversource), and Avangrid, Inc. subsidiaries Connecticut Natural Gas (CNG), Southern Connecticut Gas (SCG) and United Illuminating (UI), are here to help you save money and energy while increasing your comfort at home. If you need assistance completing this application, please call (203-292-8088). Note: If you live in a building with five or more units, please visit EnergizeCT.com/Multifamily for more information.

Section 1: Property Information (1-4 Units)

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Number of Units in the Property

Type of Dwelling

Single family home
Apartment building with 4 units or less
Condominium

Property Type Owner/Landlord

Section 2: Applicant and Energy Information

Name

First

Last

Phone

Primary Heating Fuel Type (Check one, if known)

Electric
Natural Gas
Oil
Propane

Applicant is the (Check one)

Property Owner/Landlord
Renter/Tenant

Electric Utility (Check one)

Eversource
UI
Other

Electric Account Is Listed Under

Applicant
Other Account Holder's Name
Landlord/Property Owner
Other

Electric Account Number

Natural Gas Utility (Check one)

CNG
Eversource
SCG

Natural Gas Account Is Listed Under

Applicant
Other
Other Account Holder's Name

Natural Gas Account Number

Section 3: Applicant Qualification Information

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 the applicant is enrolled in one of the following programs.

Eversource:

Electric Discount Rate
Matching Payment Program

CNG, SCG, UI:

Low-Income Discount Rate
Bill Forgiveness Program
Matching Payment Program

Option B: If the applicant has one of the following, please check the box and provide a copy to ieapp@ne-smartenergy.com.

Letter/Voucher Confirmation

EBT Award Letter for Supplemental Income Recipients
Energy Assistance Award Letter
Section 8 Housing Choice Voucher

Option C: If the applicant meets the household maximum annual gross income requirements—please send Proof of Income to ieapp@ne-smartenergy.com.

Household Maximum Annual Gross Income Information Table

How many people live in your household?

How many people live in your household who are age 18 or older?

Annual gross income of all household members age 18 and older:

Copies of information proving total household income are required. Please see Option C instructions.

I 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, that 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 installation. I understand that if the income-qualifying information I have supplied is incorrect, I may be charged for the energy efficiency program services I received through the Home Energy Solutions – Income Eligible program.

Applicant Signature (Required)

Clear Signature

Date

Note: This program is subject to change based on available funding.

Section 4: Property Owner/Landlord Authorization

(Note: if applicant is not the property owner, the property owner’s consent and signature are also required)

Option D: If Option D is selected, the property owner must complete the following table for all the units.

Ownership Confirmation

I am the owner or landlord of a property with 2-4 units and at least 50 percent of the tenants may qualify for Home Energy Solutions – Income Eligible.

Property Owner/Landlord Name

Primary Heating Fuel

Address

Address Line 1

Address Line 2

City

State

Zip Code

Tenant/Resident Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

I am the property owner of the single family or 2–4 unit property listed in Sections 1-3, and/or 4. Pursuant to Connecticut state law Title 47a-16 Landlord and Tenant. Chapter 830 - Rights and Responsibilities of Landlord and Tenant, I authorize Eversource, CNG, SCG, UI and their employee(s), subcontractor(s) or agent(s) (“Authorized Parties”) to enter the premises for a Home Energy Solutions – Income Eligible assessment and perform weatherization services at no cost to me, and provide verification services to confirm proper installation of any applicable measure. Pursuant to the Statute, I will advise the tenants of said property the date and time that the Authorized Parties will enter the premises for a home energy assessment and any following weatherization services.

Property Owner/Landlord Duly Authorized Signature

Clear Signature

Date

Note: A separate Home Energy Solutions – Income Eligible application must be completed by each applicant/tenant using Option B or Option C. If using these options, both the applicant and the property owner/landlord will need to sign the application.

Home Energy Solutions – Income Eligible

Zero Income Affidavit

Instructions: Please complete the Zero Income Affidavit only if you qualify with Option C and you have household members over the age of 18 without an income.

I (account holder name),

Account Holder Name

affirm that no adult over the age of 18 years, listed below, who lives in my household, has had any income in the four weeks prior to the date this affidavit is signed. This includes income from employment, a pension, unemployment or worker’s compensation, cash assistance from the Connecticut Department of Social Services (including Temporary Family Assistance, State Supplement or the State Administered General Assistance Program), benefits from the Social Security Administration or Veterans Benefits Administration, child support, alimony, interest or any other income source.

Note: List all people in your household, including yourself (if applicable), who are over the age of 18 and are without an income:

Name(s)

I understand that the Sponsors of Energize CT may request supporting documentation regarding my household income. I affirm that the information indicated on this form is accurate.

Signature:

Clear Signature

Printed Name:

Date:

Phone