MEAP 2025-2026 Pre-Needs Assessment
Page 1
Energy Security Plan
This Pre-Needs Assessment allows a caseworker to develop an Energy Security Plan based on your responses. A caseworker will contact you to go over your answers and the Energy Security Plan prior to its enactment. Below are the certifications required by the state. You are not required to check these now, however doing so can save time once a caseworker calls to complete these steps.
As part of this MEAP Energy Security Plan Agreement, I:
Understand that I may be referred to or requested 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 are required in order to receive additional energy assistance benefits.
Hereby grant the assisting agency or department authority to release my name and address to the local weatherization operator as part of the Weatherization Referral system.
Hereby affirm to have read the above Energy Security Plan Agreement or had it read to me by a MEAP Representative and will follow the outlined services listed in Parts A – D.
I/we authorize the caseworker to execute the MEAP Energy Security Plan with my verbal consent in lieu of my signature after the MEAP Energy Security Plan has been completed and reviewed with me.
Applicant Information
First Name
Last Name
MDHHS Case ID/NO ID
Primary Email
Primary Phone Number
County of Residence
Address
(Number and Street Name, Apt., etc.)
City
State
Please select...
MI
Zip Code
Housing Information
What is your housing situation?
Please select...
Own
Land Contract
Rent
Pay lot rent for mobile home
Other (please describe)
If Other, please describe:
What type of home do you live in?
Please select...
Single Family
Apartment
Manufactured
How many units?
Please select...
Single Family
2-4 units
More than 4 units
Are any of your utilities provided by one of the following companies?
Consumers
DTE
My Provider is Not Listed
SEMCO
UPPCO
If yes, would you be interested in enrolling in an affordable payment plan?
Please select...
Yes
No
My household does not use any of these utilities
Must be MEAP Eligible.
Housing Concerns
Thinking about the place you live; do you have problems with any of the following?
Major appliances not working
Smoke detectors missing or not working
Concerns about faulty wiring
Holes in my walls, ceiling, or roof
Pests, bugs, ants, or mice that may impact the structure of the home
Lead paint, or lead pipes. or mold problems
Water leaks
Problems with plumbing, well, or septic
None of the above
Thinking about the place you live; do you have any of these heating or cooling problems?
My heating is not working right.
I don’t have a good way to cool my home.
The temperature is different throughout the house.
There are drafts near doors or windows in my home.
None of the above
The home energy assessment will provide recommendations for services that can help you save energy and money. If your household is eligible, would you like a call to schedule your home energy score? Please note that apartment complexes and Multi Family (3 or more units) are not eligible.
Please select...
Yes
No
N/A
Questionnaire
Are you worried or concerned that in the next two months you may not have stable housing?
Yes
No
Within the past 12 months, did you worry that the food you bought wouldn’t last and you wouldn’t have money to get more?
Yes
No
I would like to talk about my food situation
Does anyone in your household
need help finding a job or finding better job?
Yes
No
Do you want help with school or training? For example, starting or completing job training or getting a high school diploma, or GED.
Yes
No
Does lack of reliable transportation keep you from appointments or work?
Yes
No
Do
problems getting childcare make it
difficult for you to work or study?
Yes
No
Do you have someone to help you if you need help with day-to-day activities such as bathing, preparing meals, shopping, caring for family members, managing finances, etc.?
I don't need any help.
I get all the help I need.
I could use a little more help.
I need a lot more help.
Page 2
Budget Survey
This section is
OPTIONAL.
If you choose to fill this out we may review it with you and offer referrals based on your answers.
Budget Breakdown
Income
Monthly NET income for the home
Housing
Rent/Mortage/etc.
Utility Bills
Heat, Electric, and Water/Waste
Other Household Bills
WiFi/Phone/Cable/Snow Clearing/etc.
Food Costs
Include Groceries and Eating Out
Childcare
Medical Costs
Prescriptions/Co-Pays/etc.
Home and Personal Care Items
Paper towels, shampoo, laundry, clothes etc.
Debts
Student loans, credit cards, medical, etc.
Other
Other
Are there any unusual costs that you foresee coming up in the next 3-6 months?
Car/home repair, back-to-school supplies/etc.
Contact Information