Energy Security Plan

MICHIGAN ENERGY ASSISTANCE PROGRAM

MEAP Energy Security Plan

SUPERIOR WATERSHED PARTNERSHIP

1104 N Third Street

Marquette, MI 49855

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

E-mail: meap@superiorwatersheds.org

Household Information

List everyone who lives in your home, including adults and children temporarily absent due to illness or employment. People are considered members of your household if they sleep and keep their belongings in your home.

MDHHS SER CASE ID:

Account Holder Information

Last Name

First Name

Middle Initial

Date of Birth

How many other persons live in your household?

Phone

How do you prefer to receive information?

Additional Family Members

Household Address (Service Address)

Address Line 1

City

State/Province

Zip Code

County

Is the Mailing Address different than the Service Address?

YesNo

Mailing Address, if different than above

Address Line 1

City

State/Province

Zip Code

County

Additional Information Needed

Home Heating Credit (HHC): Have you applied for or received the HHC (Energy Draft) in the last 6 months?

If Yes, Month Received

Have you received energy assistance from another agency or through a provider sponsored program since October 1st?

If Yes, list provider, date, amount.

How do you heat your home?

*Electric heat sources include solar panels, boilers, radiators, or baseboard heating but DO NOT include space heaters.

Electric (non-heat) Provider Information

Name of Company/Energy Provider

Name on Account

Account Number

Heat Provider Information

Name of Company/Energy Provider

Name on Account

Account Number

Water Provider Information

Name of Company/Energy Provider

Name on Account

Account Number

Waste Provider Information

Name of Company/Energy Provider

Name on Account

Account Number

Self-Sufficiency Plan

Affordable Payment Plan (APP)

The Affordable Payment Plan (APP) is available for customers of DTE Energy, SEMCO Energy and Upper Peninsula Power Company. This 24-month program allows customers to make affordable monthly payments based on household income and household energy consumption. The terms and conditions for these programs can be found as attachments to this document. Your household must be approved through State Emergency Relief before APP enrollment.

My energy provider is one of the following:

Affordable Payment Plans (Please check one).

Terms and Conditions of this plan are available with an Access Partner or on the SWP website.

Workshop Requirement

I have been informed that I am required to take the Energy Conservation & Money Management Workshop in order to qualify for any energy assistance payments from the SWP MEAP.

Home Energy Score

* Developed by the DOE and its national laboratories, the Home Energy Score provides home owners, buyers, and renters directly comparable and credible information about a home's energy use. Each Home Energy Score is shown on a simple one-to-ten scale, where a ten represents the most efficient homes. This tool will be utilized for future weatherization projects.

Signature Requirement

Please sign below after reading the following information on, otherwise this application will be considered incomplete.

As part of this MEAP agreement, I understand that I may be referred to or required to participate in additional services such as budgeting assistance, energy audits, or other programs that will help my household pay energy bills and understand energy consumption. Participation in the activities outlined in this plan/agreement is required in order to receive any additional energy assistance benefits.

Yes

I authorize the assisting agency or provider to release my name and address to the local weatherization operator as part of the Weatherization Referral system. I authorize the department to release case and payment information to the Department of Health and Human Services, its affiliates and/or contracted agencies, for the purpose of research, study and evaluation of the Low Income Home Energy Assistance Program (LIHEAP) and the Michigan Energy Assistance Program (MEAP).

Yes

I authorize my energy company to release by phone, fax, email or their computer web site all available information about my account.

Yes

UNDER PENALTIES OF PERJURY, I SWEAR OR AFFIRM THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO ME. IF I AM A THIRD PARTY APPLYING ON BEHALF OF ANOTHER PERSON, I SWEAR THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO THE APPLICANT. TO THE BEST OF MY KNOWLEDGE, THE FACTS ARE TRUE AND COMPLETE.

Yes

Signature of applicant or head of household

Date

Signature of agency representative

Date

Agency Representative Current Phone

Agency Representative Email

Identification of applicant or authorized representative

Contact Information