SUPERIOR WATERSHED PARTNERSHIP ASSISTANCE REQUEST FORM

ASSISTANCE PROGRAMS FUNDED BY MEAP, MI IMPACT &UPPCO

Superior Watershed Partnership

Michigan Energy Assistance Program

1104 N. Third Street

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 requirements have been completed and you have been SER approved or income qualified through the SWP for the utility you are requesting assistance with.

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

Enter a date in MM/DD/YYYY format

COMPLETELY FILL OUT THIS SECTION IF YOU NEED ASSISTANCE WITH YOUR ELECTRIC

For MEAP you must have past due charges showing on your bill. Having a bill past the due date with no past due charges does not qualify for assistance.

For MI Impact you must have a bill at least one day past the due date.

Electric Provider Information

Name of company/energy provider

Account Number

Name on Account

Service Address

Electric & Natural Gas - What is your shut off date?

Enter a date in MM/DD/YYYY format

Electric & Natural Gas - Name of Account Holder, if different than applicant

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

Attach itemized bill or quote here:

COMPLETELY FILL OUT THIS SECTION IF YOU NEED ASSISTANCE WITH YOUR HEAT

For propane and fuel oil, please provide or request a quote be sent to the Superior Watershed Partnership. Please answer all the questions below so we can process your request.

Heat Provider Information

Name of company/energy provider

Account Number

Name on Account

Service Address

Electric Heat & Natural Gas - What is your shut off date?

Enter a date in MM/DD/YYYY format

Electric Heat & Natural Gas - Name of Account Holder, if different than applicant:

If this is for fuel oil or propane, what percentage is left in your tank?

If this is for wood, how many days left until you run out?

Does your propane or fuel oil provider request that the agency request the quote?

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

Attach itemized bill or quote here:

COMPLETELY FILL OUT THIS SECTION IF YOU NEED ASSISTANCE WITH YOUR WATER

For MI Impact you must have a bill at least one day past the due date. We can only assist if your provider is actively participating in our program.

Water Provider Information

Name of company/energy provider

Account Number

Name on Account

Service Address

Water - What is your shut off date?

Enter a date in MM/DD/YYYY format

Water - Name of Account Holder, if different than applicant:

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

Attach itemized bill or quote here:

COMPLETELY FILL OUT THIS SECTION IF YOU NEED ASSISTANCE WITH YOUR WASTE

For MI Impact you must have a bill at least one day past the due date. We can only assist if your provider is actively participating in our program.

Waste Provider Information

Name of company/energy provider

Account Number

Name on Account

Service Address

Waste - What is your shut off date?

Enter a date in MM/DD/YYYY format

Waste - Name of Account Holder, if different than applicant:

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

Attach itemized bill or quote here:

How would you like your determination letter?

DID YOU ATTACH YOUR ITEMIZED BILL OR QUOTE?

Contact Information