Home Energy Solutions℠ Application

Home Energy Solutions is available for a copay of just $40. This program is subject to change based on available funding. Filling out this form does not automatically qualify you for the Home Energy Solutions 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 a 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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