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ENERGY ASSISTANCE PROGRAM – CLIENT INTAKE

Client Intake Directions
Welcome to the Client Intake page for your Energy Assistance appointment. Please click on the “Client Intake Form” below to fill it out before your appointment.  Once completed, or if you’ve returned here after already completing the form, please click on “Email Client Documents” to send your household documents as attachments to our secure server.
Client Intake Form

Client Intake

Fields marked with an * are required
Does everyone in your home have a Social Security Number? *
Did you receive Energy Assistance through us last year? *
Are you or someone in your household a member of a Native American tribe? *
Do you receive Food Assistance in your household? *
Has your home been Weatherized? *
Are you interested in Free Weatherization Services? *
Housing Status *
Housing Type *
Other Energy Types
Other Cooling Sources
Are you in need of a Portable Air Conditioner?
If yes, are they currently living with you?
If yes, are they your spouse?

Please check all sources of income received by any and all members of your household listed above.

Household Income *

Please answer the following for yourself, and click the "Add Another Household Member" button to do the same for every other person living in your household.

Household Members 1
Date of Birth (MM/DD/YYYY) *
Race (please select all that apply) *
Ethnicity *
Are you Disabled? *
Are you a Military Veteran?
Do you have Health Insurance? *
Military Veteran? *
Email Client Documents
SEND EMAIL

Please upload scans or clear pictures of each document. Please include the primary applicant’s name in each document’s filename. The following documentation is required for each household, as applicable:

  • Picture I.D. for the primary applicant.
  • Social Security Cards for ALL household members INCLUDING children.
  • If you do not have a Social Security number or are a non-citizen, you must provide ID for each person. Program eligibility will be determined during the application process.
  • Verification of physical address.
  • Verification for ALL income/monies received into the home from ALL sources and for EVERY household member for the 3-months indicated. Example: If your appointment is in December we will need proof of all income received in September, October, and November. It is recommended you bring in income information for the current month as well.
  • A current heating bill for the residence.
  • If you indicated “Self-Employed”, please contact our office to request a self-employment form. We will require documentation of ALL self-employment income received during the time frame indicated, i.e., business bank statements and documentation of business expenses incurred during the time frame.
  • If heat source is propane, oil, or pellets, a recent receipt or delivery ticket.
  • If heat source is wood, a statement from someone (a neighbor, friend, landlord, etc.) who can state that your main source of heat is wood.
  • If heat is included in your rent, a statement from your landlord, a rental agreement, or lease that shows proof that heat is included in rent.

Anyone with zero (‘0’) income and who is 18 or older will be required to complete paper work explaining how he/she paid for food, shelter, and heat at the time of the appointment. If you are a student, your Financial Aid award letter is required.

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