Energy Assistance Request Form

Superior Watershed Partnership

Michigan Energy Assistance Program

401 E. Fair Avenue

Marquette, MI 49855

Phone (906) 273-2742 Fax (906) 273-2741

E-mail: meap@superiorwatersheds.org

This form is to be completed only after your minimum self-sufficiency requirements have been met.

Household Information

Last Name

First Name

Middle Initial

Address on bill (Numbers & Street Name, Apt., etc.)

City

State

Zip Code

Phone Number

MDHHS Case Number

Date of Request

Completely fill out this section if you need assistance with your electric.

Electric Provider Information

Name of Company/Energy Provider

Company Address - Street Address

Company Address - City

Company Address - State

Company Address - Zip Code

Account Number

Name on Account

Service Address - Street Address

Service Address - City

Service Address - State

Service Address - Zip Code

Do you have a past due charge or shut off notice on your bill?

What is your shut off date?

Did you attach your itemized bill or quote to this request?

Attach itemized bill or quote here:

Is this bill in someone else's name?

If Yes, explain:

Completely fill out this section if you need assistance with your heat.

Heat Provider Information