Fillable ENERGY ASSISTANCE APPLICATION Step 3Step 2Step 1 (State of Maryland)

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ENERGY ASSISTANCE APPLICATION Step 3Step 2Step 1 (State of Maryland)

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• If any adult household member (18 years or older) has not received any income in the last 30 days, a Declaration
of Zero Income form must be signed. If no one in your household has received any income in the last 30 days,
a Household Worksheet must be completed. Forms may be found at http://www.dhr.state.md.us/energy or by
calling the number below.
Social Security Number Verication for all Household Members
• Social Security cards or other federal government-issued documents with name and SSN
Energy Bill Verication
• Most recent electric and heating (if applicable) bill
To check the status of your application online, visit myohepstatus.org.
Please allow 15 days from submission for the application to be displayed.
To check the status of your application over the phone or for other questions about the Oce of Home Energy Programs,
call 1-800-332-6347.
MARYLAND DEPARTMENT OF HUMAN SERVICES
OFFICE OF HOME ENERGY PROGRAMS
ENERGY ASSISTANCE APPLICATION
Step 3Step 2Step 1
Complete the
enclosed application
Include copies of the
required documents
listed below
Return your application
and documents to your
local OHEP oce
(Location listed on back)
Photo ID for the Applicant (Please submit one of the following)
• Driver’s license or other government issued identication card
Proof of Residence (Please submit one of the following)
• Unexpired driver’s license with current address listed
• Current lease or housing letter (within last 12 months) or rent receipt from landlord with address listed
• Mortgage statement within last 30 days
• Current property tax bill or receipt
Proof of ALL Gross Income for All Household Members
Wages (Employment)/
Tips/Commission
Self-Employment
Rental Income
Social Security
SSI/SSDI
Dividends
Interest from Savings or Checking
Accounts
Interest or Dividends received
from the redemption of bonds
Estate or Trust Fund Income
Royalties
Temporary Cash Assistance (TCA)
Temporary Disability Assistance
Program (TDAP)
Pensions
Money/Income from Annuities,
IRAs, or other Retirement
Accounts
Child Support
Alimony or Spousal Support
Workman’s Compensation
Benefits
Unemployment Insurance
Benefits
Veteran’s Pension
Mine Worker’s Benefits
Armed Forces Dependent
Allowance
Criminal Injuries Compensation
Board Payments
Monetary Gifts and
Loans,
excluding student loans
Employee strike funds where
there is no employee
contribution
Payments received by home care
providers for adult care
Railroad Retirement Benefits
Allegany County
1 Frederick Street
Cumberland, MD 21502
(301)784-7000
ACDSS.OHEP@maryland.gov
Anne Arundel County
Annapolis Oce
251 West Street
Annapolis, MD 21404-1951
(410)626-1900
energyprograms@aaccaa.org
Glen Burnie Oce
117 Delaware Avenue
Glen Burnie, MD 21061
Baltimore City
Please apply at your nearest location
Southeast Community Action Center
3411 Bank Street, 21224
(410) 545-6518
Eastern Community Action Center
1731 E. Chase Street, 21213
(410) 545-0136
Northern Community Action Center
5225 York Road, 21212
(410) 396-6084
Northwest Community Action Center
3939 Reisterstown Road, 21215
(443) 984-1384
Southern Community Action Center
606 Cherry Hill Road, 21225
(410) 545-0900
The email address for Baltimore City is:
OHEP@baltimorecity.gov
Baltimore County
6401 York Road
Baltimore, MD 21212
(410) 853-3385
ohep.mailrequest@maryland.gov
Calvert County
3720 Solomon’s Island Road
Huntingtown, MD 20639
(410) 535-1010
OHEP@smtccac.org
Caroline County
300 Market Street
P.O.Box 400
Denton, MD 21629
(410) 819-4500
caroline.care@maryland.gov
Carroll County
10 Distillery Drive, Suite G-1
P.O. Box 489
Westminster, MD 21158
(410) 857-2999
OHEP@hspinc.org
Cecil County
135 E. High Street
Elkton, MD 21921
(410) 996-0270
DLCecil_Ohep_DHS@maryland.gov
Charles County
8371 Old Leonardtown Road
Hughesville, MD 20637-0280
(301) 274-4474
OHEP@smtccac.org
Dorchester County
627 Race Street
Cambridge, MD 21613
(410) 901-4100
dorchester.ohep@maryland.gov
Frederick County
420 E Patrick Street
P.O. Box 3929
Frederick, MD 21705
(301) 600-2410
ohep@cityorederick.com
Garrett County
104 E. Center Street
Oakland, MD 21550-1397
(301) 334-9431
OHEP@garrettcac.org
Harford County
1321 B Woodbridge Station Way
Edgewood, MD 21040
(410) 612-9909
MEAP@harfordcaa.org
Howard County
9820 Patuxent Woods Drive
Columbia, MD 21046
(410) 313-6440
clientassistance@cac-hc.org
Kent County
350 High Street
Chestertown, MD 21620
(410) 810-7600
Kent.ohep@maryland.gov
Montgomery County
1301 Piccard Drive
Rockville, MD 20850
(240) 777-4450
ohep@montgomerycountymd.gov
Prince George’s County
425 Brightseat Road
Landover, MD 20785
(301) 909-6300
pgcdss.energy@maryland.gov
Queen Anne’s County
125 Comet Drive
Centreville, MD 21617
(410) 758-8000
QAC.OHEP@maryland.gov
Somerset County
12409 Loretta Road
Princess Anne, MD 21853
(410) 651-1805
Energywicomico@shoreup.org
St. Mary’s County
21775 Great Mills Road,
Lexington Park, MD 20653
301-475-5574
OHEP@smtccac.org
Talbot County
126 Port Street
Easton, MD 21601-2631
(410) 763-6745
energy@nsctalbotmd.org
Washington County
117 Summit Avenue
Hagerstown, MD 21740
(301) 797-4161
WashingtonCountyOHEP@wccac.org
Wicomico County
500 Snow Hill Road
Salisbury, MD 21804
(410) 341-9634
Energywicomico@shoreup.org
Worcester County
6352 Worcester Highway
Newark, MD 21841
(410) 632-2075
Energywicomico@shoreup.org
1
PLEASE PRINT ALL INFORMATION. Be sure to ll out all information clearly and completely.
In order to be eligible for electric grants, the bill must be in the applicant’s name. You must provide documentation to prove
information provided on this application. Documentation includes a copy of the applicant’s photo ID, proof of where you live
(this can be your utility bill), copies of Social Security Cards for everyone in your household, and proof of all gross (pre-tax)
income for everyone in your household for the last 30 days. If your household received no income in the 30 days prior to this
application, you must sign a Declaration of Zero Income and provide additional information.
MARYLAND DEPARTMENT OF HUMAN SERVICES
OFFICE OF HOME ENERGY PROGRAMS
ENERGY ASSISTANCE APPLICATION
Name
Mailing Address
City, State, Zip
Email Address
Social Security Number
Street Address
(If different from your mailing address or if you have moved)
Secondary Phone Number
Primary Phone Number
Home Cell Work Friend/Relative
Home Cell Work Friend/Relative
Is your heat included in the rent? Yes No
Landlord’s Name/Apartment Complex:
Landlord’s Mailing Address:
City:
State:
Zip:
Landlord’s Phone Number: ( )
Email Address:
2. RENTERS ONLY
My electricity has been disconnected
I have no heating fuel and/or gas
My heating system, cooling system, or
water heater is broken.
I have received notice that my electricity and/or gas will be disconnected
I have less than 3 days of heating fuel
My tank has been removed
I have received an eviction notice (If you
have an eviction notice, you may be referred
to another program)
The loss of electric/gas service will aggravate an existing serious
illness or prevent the use of life support equipment. (Physician’s
Certication is required).
3. CRISIS INFORMATION
Is your rent reduced through help from HUD or Subsidized Housing (Section 8)? Yes* No
*If you answered yes to this question, do you receive Utility Allowance? Yes No
*If you rent:
Apartment or Multi-Family Double, Row or Townhouse Single Family Home Mobile Home
Homeowner Renter Roomer/Boarder
Are you a (Check one):
1. LIVING ARRANGEMENTS
Do you live in a:
2
M/F
/ /
/ /
/ /
/ /
/ /
/ /
/ /
/ /
APPLICANT
FIRST & LAST NAME
1.
2.
3.
4.
5.
6.
7.
8.
SOURCES OF
INCOME
VETERAN
(YES or NO)
GROSS 30 DAY
AMOUNT
SOCIAL SECURITY NUMBER
BIRTHDATE
M/D/YR
RELATIONSHIP
TO APPLICANT
SEX RACE
CODE
AMERICAN
CITIZEN
DISABLED
4. HOUSEHOLD INFORMATION - Fill in all spaces below for ALL Household members, even if they are not related to you or helping nancially.
1. Black or African-American
2. White
3. Hispanic
4. Asian, Hawaiian or Pacic Islander
5. American Indian or Alaskan Native
6. Multi-Racial
Total # of household members is
Please use the following choices for “Race”:
Total # of household members 18 years and over is
Please list additional household members on a separate paper.
(YES or NO)
(YES or NO)
For each household member in the table below, list all sources of income
received in the last 30 days. Documentation of income for each household
member 18 years or older must be provided with this application. For
examples of income, and which documents we can accept for your income type,
refer to the application instructions included in this packet. If any household
members who are18 years or older have not received any income in the last 30
days, you will need a Declaration of Zero Income form.
7. Other
3
5. ELECTRIC GRANT - Electric Universal Service Program (EUSP)
6. HEATING GRANT - Maryland Energy Assistance Program (MEAP)
I want to apply for a MEAP grant. The heating bill does not need to be in my name to qualify.
I do not want to apply for MEAP. (Proceed to section 8)
My heat supplier or fuel company is:
Name on the account:
CHECK ONE BOX BELOW FOR THE MAIN HEATING SOURCE OF YOUR HOME:
Electricity Utility Gas Propane
Oil Kerosene
Coal Wood Pellets
USPP helps me prevent a shut-off as long as I continue to pay the minimum monthly payment as required by my utility supplier.
All MEAP eligible customers may participate in USPP. Participation also requires 12 months of budget billing. Budget billing
spreads your annual utility bills into even monthly payments. Failure to make consecutive payments may result in my removal
from USPP. I understand that I do not have to participate in USPP to receive MEAP benets and no money will be paid to my
account through USPP.
I want to enroll in USPP.
7. PREVENT SHUT-OFF WITH REGULAR PAYMENT - Universal Service Protection Program (USPP)
I have a past-due electric bill and would like to receive an Electric Arrearage grant to help pay the balance. I must have a past-due
electric balance of at least $300 to be considered for the grant, and I may receive up to $2,000 for my current past-due bills.
This grant
is only available once every five years, though certain waivers to this rule may apply. Electric Arrearage grants are in addition to
electric benefits applicants may receive each year through the EUSP program. I must receive EUSP, enroll in budget billing, and the
electric bill must be in my name to qualify for an electric arrearage grant.
I have a past-due gas bill and would like to receive a Gas Arrearage grant to help pay the balance. I may receive up to $2,000, once every
five years, though certain waivers to this rule may apply. Gas Arrearage grants are in addition to heating benefits applicants may receive
each year through the MEAP program. I must have a past due gas balance of at least $300 to be considered for the grant. I must receive
MEAP to be eligible for a gas arrearage grant and the gas bill must be in my name.
I want to apply and be screened for an arrearage grant and understand that, if I receive this benet, I may not be eligible for another
Electric Arrearage grant for ve years.
I want to apply and be screened for a Gas Arrearage grant and understand that, if I receive this benet, I may not be eligible for
another Gas Arrearage grant for ve years.
8. PAST-DUE ELECTRIC BILLS - Arrearage Retirement Assistance (ARA)
9. PAST-DUE GAS BILLS - Gas Arrearage Retirement Assistance (GARA)
I want to apply for EUSP. I understand I will be enrolled in budget billing for 12 months to receive an EUSP benet.
I understand that the electric bill must be in my name to qualify for EUSP.
I do not want to apply for EUSP and understand that I will not receive a benet for my electric costs. (Proceed to section 6)
Name on the account:
My electric company is:
Account number:
Turn-off notice:
My service is off:
YES
YES
NO
NO
Account number:
Turn-off notice:
My service is off:
YES
YES
NO
NO
# IN HH TOTAL HH INCOMECOUNTY CENTER
ELECTRIC ARREARAGE GAS ARREARAGE
SCREENED FOR ARA
SCREENED FOR GARA
QUALIFIES & IS
DOCUMENTED
QUALIFIES & IS
DOCUMENTED
DATE RECEIVED SUB/HUD
MEAP
ANNUAL USAGE*
BENEFIT AMOUNT
WORKER SIGNATURE
DATE DATE
EUSP GAS ARREARAGE
CERTIFIER SIGNATURE
POVERTY LEVEL
YES
YES
YES
YES
NO
NO
NO
NO
YES NO
I am interested in having energy efciency improvements made to my home. This may help me reduce my overall utility consump-
tion and help to reduce my utility bills while creating a healthier home environment. Please refer me to the energy efciency programs
provided by the Maryland Department of Housing and Community Development (DHCD). The energy efciency improvements such as,
furnace clean and tune, added insulation, and energy efcient light bulbs are offered at no additional cost to income eligible Marylanders.
Landlord approval will be required for renters participating in this program. I understand I do not need to participate in DHCD’s energy
efciency programs to receive OHEP benets.
10. ENERGY EFFICIENCY FOR YOUR HOME – DHCD Energy Efciency Programs
I swear or afrm under penalty of perjury that all the information I gave to the Ofce of Home Energy Programs (OHEP) in this Energy
Assistance Application is true, correct, and complete to the best of my ability, belief, and knowledge. I am the representative of the
individual household members identied in this application, and I submit this application on behalf of myself and the other individual
household members. I authorize OHEP and/or the Ofce of Inspector General (OIG) to investigate and conrm the accuracy and
completeness of all household income and other information provided with this application, including but not limited to the use of
governmental and consumer reporting agency data regarding employment income.
I consent to allow my gas, electric, oil company, or any other energy provider to provide relevant account information to OHEP and for
OHEP to communicate with those providers regarding this application. I allow OHEP to release and exchange relevant information with
other agencies and my gas, electric, oil company, or other energy provider in order to make appropriate referrals to services that may
assist me to lower my energy bill or help me to better afford my energy costs or help me with the completion of my application. I consent
for my information to be entered into other secure databases for tracking of services, statistical information, and program evaluation.
I understand that by checking ‘YES’ to question #10, I understand that OHEP will refer all necessary information from my application
to DHCD’s energy efciency programs. I also give my permission for DHCD to access my utility consumption data through my utility
provider(s) in order to determine the energy efciency improvements for which I may be eligible. I understand that if I decide to participate
in any of the energy efciency programs at a later date, this application is my authorization for the programs to access my utility
consumption data.
An appeal can be led to change the decision on this application or if help is not given in a reasonable time. The appeal must be led
within 30 days of the decision. The local agency will tell me how to le. Free legal advice may be available through the Legal Aid Bureau
by calling toll-free 1-800-999-8904.
Maryland has a fraud law that will be vigorously enforced for intentional misrepresentations of information contained on this application.
Punishment can occur for not telling the truth when applying for assistance to pay home energy costs. If a household member
intentionally misrepresents information, that member may be disqualied from the program for a set amount of time.
YES. I want to receive energy efciency improvements. I understand that my application information will be referred to DHCD AND I give
my permission for DHCD to access my utility consumption data through my utility provider(s) in order to determine the energy efciency
improvements for which I may be eligible.
11. ACKNOWLEDGEMENT & SIGNATURE – You or your representative must sign this application before submitting.
DateApplicant’s Signature
OFFICE USE ONLY:
WORKER’S COMMENTS
DOES NOT QUALIFY BECAUSE:
RECEIVED IN 5 YRS
ARREARAGE < $300
DOES NOT QUALIFY BECAUSE:
RECEIVED IN 5 YRS
ARREARAGE < $300
*If no usage, indicate the type of fuel or whether the heat is sub-metered.
4
ELECTRIC ARREARAGE
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Completed 31 January 2022

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