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Applicant Information

First Name

Last Name

Date of Birth

MDHHS Case ID/NO ID

Do you have a disability or a physical/emotional/mental health condition?

Yes

Part A – Household Information

How many people are in your household?

Is anyone in your household under the age of 5?

YesNo

Is anyone in your household over the age of 60?

YesNo

Please list everyone who lives in your household, including their date of birth.

A Household Member includes the following people: Adults, children, children temporarily absent due to illness or employment, and anyone who sleeps and keeps their belongings in your home.

First Name

Last Name

Relationship to You

Date of Birth

Does this person have a disability or a physical/emotional/mental health condition?

YesNo

Has anyone in your household experienced homelessness in the past 12 months?

YesNo

Part B – Household Address and Contact Information

Household Contact Information

Primary Email

Primary Phone Number

Household Service Address

Address (Number and Street Name, Apt., etc.)

City

Zip Code

County

Mailing Address (if different than above)

Street Name, Numbers, PO Box #

City

Zip Code

County

Before Next Section

Are you reapplying for MEAP assistance since October 1, 2025?

YesNo

If yes, has your income or categorical eligibility changed since your last MEAP or SER application during this program year?

Yes (Complete all sections within application.) No (Please skip to Part I and complete #5, #6 (if applicable), and signatures.)

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Part D – Emergency Need

How do you heat your home?

WoodPropaneCoalNatural GasFuel OilOtherNo ObligationElectric Heat(Includes solar panels, boilers, radiators, or baseboard heating, DOES NOT include space heaters)

If Other, explain here:

Check the service(s) you are requesting and the amount needed to resolve the emergency for 30 days. PLEASE NOTE: We will only assist with either Heat and/or Electricity if you check the below boxes.

HeatElectricity (non-heating)I am not facing an emergency at this time.

Heat

Amount Needed to Resolve Emergency

If Prepaid Account, Amount in Account

If Deliverable Fuel, % Remaining in Tank?

(Payment for deliverable fuel will not be made if, at the time of delivery, it is confirmed that you have more than 30 percent of the fuel remaining in your tank.)

Please attach itemized HEATING utility bill or quote.

Electricity (non-heating)

Amount Needed to Resolve Emergency

If Prepaid Account, Amount in Account

Please attach itemized ELECTRIC utility bill.

Part E – Heating Provider Information

Account Number

Name of Provider

Name on Account

Service Address

Service City

Service Zip Code

Has your heat been turned off or have you run out of your only heating fuel source?

YesNo

If Yes, date service was turned off or when fuel ran out:

Have you received a past due or shut off notice?

YesNo

If Yes, date service is scheduled to be turned off:

Are you at risk of running out of your only heating fuel source?

YesNo

If Yes, number of days until fuel runs out:

Part F – Electric Provider Information

Account Number

Name of Provider

Name on Account

Service Address

Service City

Service Zip Code

Has your electricity been turned off?

YesNo

If Yes, date service was turned off:

Have you received a past due or shut off notice?

YesNo

If Yes, date service is scheduled to be turned off:

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Part C – Categorical Eligibility

Have you or do you currently receive benefits from Michigan Department of Health and Human Services (MDHHS)?

YesNo

Please check all the benefits you receive:

Food Assistance Program (SNAP/FAP)	Head Start
Women Infants Children (WIC)	Family Independence Program (TANF/FIP)
State Disability Assistance (SDA)	Supplemental Security Income (SSI)
Other

If Other, explain here:

Household Proofs

Please attach proofs for the program(s) in which any household member is currently enrolled.

Proof of Program Enrollment

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

YesNo

If yes, who was the provider?

Have you applied for State Emergency Relief with MDHHS or MI Bridges for this need in the last 30 days?

YesNo

Have you applied and been approved for a Home Heating Credit through the Department of Treasury for the current or previous tax year?

YesNo

Part G – Household Income

Does your household have any income?

YesNo

If Yes, total monthly income

Please check all sources of income that your household expects to receive in the next 30 days and attach proofs.

Child support	Pension/retirement benefits	Unemployment
Disability benefits	Self-employment income	Veteran’s benefits/Military allotments
Employment/earned income	Social Security benefits	Worker’s Compensation
Money from family/friends	Supplemental Security Income (SSI)	Other, please list (ex: lottery winnings)
Rental income or a land contract, mortgage or other payment payable to a household member	Tribal payments (Energy Assistance/LIHEAP, tribal GA, casino/gambling profit sharing, land claims, etc.)

If Other, explain here:

Recipient Info

First and Last Name	Type of Income or Name of Employer (If employed)
Gross Monthly Income (Amount before taxes and expenses)	How Often Received (Weekly, biweekly, monthly, etc.)

Household Proofs

Please attach proofs of any income for the home. Please contact our office with any questions or issues with submissions.

Proof of Household Income

Part H – Deductible Expenses

Check all expenses your household pays and attach proof for each checked item.

Health Insurance Premium

Amount

Paid How Often?

Covered Time Period

(1 mo., 3 mos., etc.)

Actual Childcare Costs (Paid by the employed person, not MDHHS)

Amount

Court Ordered Child Support

Amount

Unusual Employment Related Expenses

Amount

Explain expense:

Deductible Proofs

Please attach proofs of any checked deduction above if not included in your eligibility proofs (i.e. directly deducted from your paystub or benefits)

Proof of Household Deduction

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Part I – Certification

(Check the box to each certification statement below.)

I/we hereby affirm to provide all requested verifications within eight calendar days and understand failure to do so may result in denial of the application

I/we 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.

I/we authorize the release of my 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)

I/we hereby grant the energy provider(s) listed in Part E authority to release all available information about my/our account by phone, fax, email and/or the energy providers website.

I/we hereby affirm to have read the application, or had it read and examined by the authorized representative and with knowledge of the penalties for false statements, certify that the statements and information contained in this application are true to the best of my/our knowledge and belief.

I/we authorize the caseworker to execute the MEAP Application with my verbal consent in lieu of my signature after the MEAP Application has been completed and reviewed with me.

Signature Section

Signature of Applicant or Reapplicant