Home Energy Solutions Application

Due to potential high customer participation and program oversubscription, we reserve the right to restrict services to homes that could benefit the most. This program is subject to change based on available funding. Currently, until Dec 31, 2023, the co-pay for the energy assessment is $50. Attention: the co-pay will be going up to $75 starting January 1, 2024. Filling out this form does not automatically qualify you for the Home Energy Solutions^SM Program. if your home is selected, you will be notified via letter or telephone. An authorized adult must be present during the assessment and provide access to the premises. Click here for printable copy.

Contact Information

Fields marked (*) are required. Please use name and address as printed on utility bill.

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First Name *

Last Name *

Address *

Address Line 1

Address Line 2

City

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Zip Code

Email *

Phone *

Other Phone

Electric Acct # *

Option

• Eversource
• UI
• Other

Natural Gas Acct # (if using gas) *

providers

• CNG
• SCG
• Eversource
• Other
• None

About My Home

• Apartment
• Single Family
• Condo
• Duplex

I live in my house:

• Year-round
• Part of the year

Age of Home

Heated Square Footage of Home: *

Do you

• Rent
• Own

Primary Source of Heat *

• Electric
• Forced Hot Air
• Hot Water
• Baseboard
• Other

If other, please describe

Do you have an oil, propane or kerosene heating service contract?

• Yes
• No

Primary Heating Fuel Type *

• Electric
• Gas
• Oil
• Propane
• Other

If other, please describe

Primary Hot Water Type

• Electric
• Gas
• Oil
• Propane
• Other

If other, please describe

Central Air Conditioning

• Yes
• No

If yes, enter age of Central A/C (in years)

Household Income

• $0–$41,553
• $41,553–$54,338
• $54,338–$67,124
• $67,124+

How many individuals live in your home?

How did you hear about the Home Energy Solutions Program?

• Bill Insert
• Direct Mail
• Radio
• TV
• Other

If other, please describe

Have you participated in any in-home utility conservation programs within the past six years?

• Yes
• No

If yes, please describe

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