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IMPORTANT NOTICE How to Apply for the Energy (State of Nevada, Department of Information Technology)

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IMPORTANT NOTICE
How to Apply for the Energy Assistance Program (EAP)
Submit a completed application (to include the name, date of birth and Social Security Numbers
for EVERY PERSON who lives in your home) with the following verification:
1. Proof of identity for the head of household (such as a driver’s license, government issued
I.D., school I.D., etc.) and;
2. Proof of citizenship or legal status if born outside of the United States and;
3. Proof of where you live:
a. Provide a complete copy of your rental/lease agreement (listing all persons in your
home) and the signature page, or
b. a copy of your mortgage statement and;
4. Provide a copy of most recent heating/cooling bills and;
5. When the utility bill is not in the applicant’s name, proof of identity for the individual
listed on the utility bill is required along with written authorization for the applicant
to apply, that includes their address, phone number and signature and;
6. Proof of ALL income for EVERY PERSON in the household for at least the last thirty
(30) days.
Examples of types of income: Employment, child support, social security, Veterans
benefits, retirement, public assistance, utility reimbursements, unemployment
insurance, interest income, money from family and/or friends, or organizations,
educational scholarships and/or grants, etc.
Note: If the employed individual is working through an employment agency, provide
proof of the last 12 months of earned income.
7. If the household expenses exceed the household income, proof of how the household is
meeting their needs.
**FAILURE TO PROVIDE THIS INFORMATION MAY DELAY THE
PROCESSING OF YOUR APPLICATION. **
Prior year recipients may not reapply until approximately 11 months after they received their last benefit.
Applications are processed in the order in which they are received.
Applicants will receive a notice of decision once an eligibility determination has been made.
Please mail or fax your application and verifications to:
Energy Assistance Program Energy Assistance Program
2527 N. Carson St., #260 3330 E. Flamingo Rd., #55
Carson City, NV 89706 Las Vegas, NV 89121
Fax: (775) 684-0740 Fax: (702) 486-1441
7/20
(Page A) 2824 – EL (7/20)
Division of Welfare and Supportive Services
ENERGY ASSISTANCE
APPLICATION
The Energy Assistance Program (EAP) is designed to help eligible Nevada households with their annual
heating and electric costs.
INCOME REQUIREMENTS
The total gross monthly income of all household members may not exceed the amounts shown in the chart
below.
YOUR HOUSEHOLD’S GROSS MONTHLY INCOME MAY NOT EXCEED:
Persons in
Home
Annual
Income
Monthly
Income
Persons in
Home
Annual
Income
Monthly
Income
1 $19,140 $1,595 5 $46,020 $3,835
2 $25,860 $2,155 6 $52,740 $4,395
3 $32,580 $2,715 7 $59,460 $4,955
4
$39,300
$3,275
8
$66,180
$5,515
(For families/households with more than 8 persons, add $6,720 to the annual income for each additional person).
Households with a chronic or long term illness, who pay out of pocket medical expenses and whose gross
income exceeds the income guidelines may have their countable income reduced by verified qualifying
expenses.
BENEFITS
Eligible households receive an annual one-time-per-year benefit called a “fixed annual credit” customarily
paid directly to their energy provider(s). The benefit shows as a credit on the bill.
MINIMUM PAYMENT – The minimum yearly payment for eligible households is $240.
WHEN TO APPLY
If your family is not currently on the program and you meet the income requirements, apply NOW.
If you received a benefit during the past 12 months, a notice will be mailed to you when it is time to
reapply. If you submit an application prior to the date you’re eligible to reapply, the application will
be denied.
WHAT DO I NEED?
Submit a completed EAP application with the required verification. Suggested income verifications are noted
on the back of this page. To get answers to other questions, call:
Reno/Carson City (775) 684-0730
Las Vegas (702) 486-1404
Toll Free (800) 992-0900
Visit our website at: http://dwss.nv.gov for more information on the program requirements.
You can find information about the Weatherization Assistance Program at:
http://housing.nv.gov/programs/Weatheriztion/
(Page B) 2824 – EL (7/20)
DOCUMENTATION EXAMPLES OF REQUIRED PROOF OF INCOME
All documentation sent with your application can be either originals or photocopies. If you are unable to
photocopy the originals, our office will copy the material and if requested we will send it back after your case
has been processed.
Earned Income: Includes income from employment, self-employment (see below), child care services, house
cleaning, and/or any service for which you are paid. Provide copies of check stubs (if paid in cash, a statement
from the person who paid you for a service) for at least the last thirty (30) consecutive days. If paid weekly
– 4 check stubs; paid bi-weekly or semi-monthly – 2 check stubs. If you do not have check stubs, a signed
and dated statement on letterhead from your employer stating your gross income for the last thirty (30) days
and how often you get paid, is acceptable. If working through an employment agency or on-call provide proof
of the last 12 months of income.
Self-Employment/Non-Profit Business Income: May include profit and loss statements signed by the
applicant detailing gross income and expenses (receipts must be provided for deductions) during the last 12
months, a copy of the sales tax statement showing gross net proceeds, financial statements, a loan application
listing income and expenses for the last 12 months, or DWSS Form 2011 that includes receipts for allowable
deductions. Allowable deductions include: cost of goods sold, supplies and materials, advertising, accounting
and legal fees, wages paid to employees, office space rent/mortgage, telephone, utilities, transportation costs
necessary to produce income, etc.
Unearned Income: Includes income from the Social Security Administration, Veterans Administration,
pensions, disability, military service, unemployment, child support, alimony, interest, dividends, regular
insurance or annuity payments. If you are receiving Social Security, SSI, Veterans Benefits, pensions,
disability income, military income or unemployment: provide copies of the benefit verification form or
award letter for the current year showing any cost of living raises. If you are receiving child support/alimony
income: provide a copy of divorce decree/separation/settlement agreement, or dated letter from the person
paying the support (to include name, address and phone number), or a copy of the last check/statement from
the child support enforcement agency. If you are receiving interest income/dividends: provide 12 months
of bank account statements, certificates of deposit or other documentation that contains details and is signed
by the financial institution, or a broker’s quarterly statement showing earnings.
Cash Contributions and/ or Recurring Gifts: If someone is helping you pay your expenses or is giving
you money: provide a signed statement from each person that includes their name, address, phone number, if
the assistance will continue, and the amount provided to you during the last six months. Provide a signed and
dated statement by the person providing the money indicating the amount of support, how often it is paid,
when the arrangement began, and whether it is paid directly to a vendor or in cash to you. The statement
must include the contributor’s printed name, address(es), and phone number(s).
Student Income: Includes ALL scholarships and grants, e.g., Pell Grant, Federal Supplemental Educational
Opportunity Grant (FSEOG), Veterans Administration educational benefits, etc. Please provide written
confirmation of the amount of assistance, and the educational institution’s written confirmation of the cost
for the prior two (2) semesters and summer school (if applicable) of the student’s tuition, fees, books and
equipment. If benefits are paid directly to the student, copies of the latest benefit checks or canceled checks
or receipts for tuition, fees, books, and equipment are acceptable.
Public Assistance Income: Includes but is not limited to TANF, county general assistance, Clark County
Social Services, or American Indian/Alaska Native General Assistance. Provide a written statement from the
public agency with the amount paid during the last month, or a copy of the award letter or check.
PLEASE NOTE: 1099 and W-2 forms by themselves are not acceptable as proof of income.
(Page 1 of 6) 2824 – EL (7/20)
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
ENERGY ASSISTANCE PROGRAM
MAIL OR FAX YOUR APPLICATION TO ONE OF THE OFFICES LISTED BELOW
LAS VEGAS / NORTH LAS VEGAS
3330 E. Flamingo Rd., #55, Las Vegas, NV 89121
Telephone: (702) 486-1404 Fax: (702) 486-1441
OFFICE FOR ALL OTHER AREAS
2527 N. Carson Street, Suite 260, Carson City, NV 89706
Telephone: (775) 684-0730 Fax: (775) 684-0740
APPLICATION FOR ASSISTANCE
Please complete every section and answer each question. Sign the application and the Rights and Obligations form. Failure to
complete all sections and questions and/or sign the application and Rights and Obligations, OR provide the requested
documentation noted on the application, will delay processing your application and may result in your application being denied.
A. APPLICANT/HOUSEHOLD INFORMATION
Complete the following for every person living in your home, including yourself (attach additional page if necessary). The first name
on the application should be the applicant (person listed on the utility bill in the home). Provide proof of identity for the applicant.
Name
(Last, First, Middle)
(Jr., Sr., III)
Relationship to
You
SELF
S
E
X
M/F
Date of
Birth
(mm/dd/yy)
A
G
E
U.S. Citizen
or Eligible
*Non-citizen
Yes
No
Disabled
Yes
No
Social Security
Number
Are there additional people in your home?
YES
NO If “YES,” list them on a separate sheet of paper.
Home Address (include apartment or unit number) City State Zip
Mailing Address (If different from your home address.) City State Zip
Home Phone
( )
Day/Message/Cell Phone
( )
E-mail Address
*List the names of non-citizen household members authorized as legal residents of the United States:
*Provide copies of the front and back of their I-551 (Resident Alien Card) with this application.
B. DWELLING INFORMATION
Renters: Provide a complete signed copy of rent or lease agreement dated within the last 12 months, listing every person living
in the home(s). If subsidized, provide signed Housing documents listing every person in the home, rent and utility rebate.
Buyers/Owners: Provide copy of mortgage statement, or proof of payoff, or current tax information.
1. Dwelling Type:
House
Apartment Condo/Townhome
Rent Room Mobile Home
Duplex
Motel/Hotel Studio
Travel Trailer
Other:
_____________________
2. Dwelling Cost:
Rent $
____________
Subsidized Rent $
___________
Space Rent $
_________________
Buy $
____________
Own When did you pay off your mortgage?
_______________
3. Rent/Buyers only: Landlord, Project/Complex, Mortgage Company Name:
________________________________________
Address:
_____________________________________________________
Telephone No.: (_____)
__________________
4. Do you reside in subsidized housing where heating and electric are included in the rent?
YES
NO
IF YES, select all that apply:
Section 8
Section 42
Other:
________________________________________
C. HELP US BETTER SERVE OTHERS
How did you hear about the Energy Assistance Program? Check one that most applies:
TV Friend Previous EAP Participant Other: Please identify
Radio
Landlord
Received Notice in Mail
_____________________
Print Media
Utility Company (flyer or employee)
Social Service Employee
(Page 2 of 6) 2824 – EL (7/20)
D. UTILITY INFORMATION
ELECTRIC SERVICE
(Attach Copy of Bill)
Check one that applies:
Receive bill from utility company
Electric service included in rent/mortgage
Pay separate bill to landlord for electric service
_______________
(Electric Company Name)
(Electric Account Number)
(Name On Account)
Is the person listed on the account your landlord?
YES
NO
(If the account holder does not live with you provide their address,
telephone number, relationship to you, proof of identity for the person
who is named on the utility bill, and a statement authorizing you to apply
for benefits on their behalf.)
ARREARAGE ASSISTANCE (Once in a Lifetime)
Do you have past due charges with your electric utility and want
assistance to pay this debt?
YES
NO
HEATING SERVICE
(Attach Copy of Bill)
Check primary heating source:
Natural Gas Electric Propane Fuel Oil
Kerosene Wood Other
Check one that applies:
Receive bill from utility company
Heating service included in rent/mortgage
Pay separate bill to landlord for heating service
(Heating Company Name)
(Heating Account Number)
(Name On Account)
Is the person listed on the account your landlord? YES NO
(If the account holder does not live with you provide their address,
telephone number, relationship to you, proof of identity for the person who
is named on the utility bill, and a statement authorizing you to apply for
benefits on their behalf.)
ARREARAGE ASSISTANCE (Once in a Lifetime)
Do you have past due charges with your heating utility and want
assistance to pay this debt?
YES
NO
If your energy provider is NV Energy or Southwest Gas, you need to provide a copy of your current utility bill. For all other energy
providers, proof of the last 12 months of usage in dollars and therms, watts and/or gallons for your current address will be required. Proof
can be in the form of your last 12 months bills or a print-out from your energy provider.
E. HOW DO YOU WANT YOUR BENEFIT PAID?
Choose how you want your benefits paid: (Mark ONLY One)
Split my benefit between my
electric and heating provider.
Pay my entire benefit.
to my heating provider.
Pay my entire benefit
to my electric provider.
If you choose a split payment your benefit will be split between both of your energy providers not to exceed your annual usage per
provider. The benefit may not be an equal 50/50 split.
If you choose a single payment your benefit will be paid to cover your annual usage for that provider, and if there is a remaining
balance, it will be paid to your second provider.
If you do not choose one of the options above, your benefit will be split between both providers not to exceed the annual usage per
provider.
F. INCOME
1. EARNED INCOME: Does any member of the household, regardless of age, work?
YES
NO If YES, complete the
information below: (Include self-employment, business, child care, housecleaning, odd jobs, temp agencies, and non-profit
organization income)
NAME OF PERSON WORKING EMPLOYER
DATE OF
HIRE
TYPE OF
WORK
GROSS
PAY
PER
CHECK
HOW OFTEN
PAID
TIPS PER
MONTH
List all household members, age 18 or older, who are not currently employed:
NAME OF PERSON FORMER EMPLOYER
DATE LAST
WORKED
GROSS PAY
PER CHECK
DO YOU EXPECT RE-EMPLOYMENT
PENDING SSI? If YES, explain.
Attach copies of all check stubs or other proof of gross income for at least the last thirty (30) days even if the person is no
longer employed. 1099s and W-2s by themselves are not acceptable proof of income. EXCEPTION: Self-employment
requires 12 months profit and loss statements.
(Page 3 of 6) 2824 – EL (7/20)
2. UNEARNED INCOME: Complete the following, indicating who, if anyone, receives money or benefits from the sources listed
below. You must mark YES or NO for each income type and attach proof of all unearned income. 1099s and W-2s by
themselves are not acceptable proof of income.
YES
NO
INCOME TYPE
PERSON
RECEIVING
GROSS
AMOUNT
FREQUENCY
Alimony
Boarders / Roomers (Attach notarized proof of rental or lease)
Child Support
Contribution / Gifts / Church or Charitable Donations
Educational Assistance / Student Loans
(Attach proof of tuition, books and supplies for prior TWO semesters)
Food Assistance (Supplemental Nutrition Assistance Program-
SNAP) In Nevada? Yes No If No, which State?
Foster Care
County Assistance / General Assistance
Interest / Dividends / Annuities / Royalties
Loans
Lump Sum Payments (Settlements / Back Pay, etc.)
Military Income / Allotment
Mining Claims
Panhandling
Pensions / Retirement
Property Rentals / Sale
Railroad Retirement
Room Rental (Attach notarized proof of rental or lease)
Social Security Benefits (RSDI)
Strike Benefits
Subsidized Housing
Supplemental Security Income (SSI)
Supported Living Arrangement (SLA)
TANF Assistance
Tribal Assistance / Indian General Assistance (IGA)
Trust Income (Provide proof if it is not accessible)
Unemployment Insurance
Utility Allowance / Rebate Check
Veterans Benefits
Winnings
Worker’s Compensation or Temporary Disability
Other
MEETING EXPENSES:
1. If the household expenses (e.g. rent, utilities, food, etc.) are more than your household’s income, explain how you are able to
meet these expenses.
2. If someone is helping you meet your expenses or is giving you money, you must provide a signed statement from each person
that includes their name, address, telephone number and amount of help they provided to you during each of the last six months.
Below, fill out the information of the person(s) who provided you a statement:
_____
Name of Person Assisting Address Phone Number Amount How often
Do you expect any changes in the household’s income or benefits?
YES
NO
If YES, what?
__________________________________________
When?
___________________________________________
Changes in income prior to certification will be used to determine eligibility.
(Page 4 of 6) 2824 – EL (7/20)
G. RESPONSIBILITY
Information provided in this application is subject to verification and investigation by federal, state and local officials. If you make a
false or misleading statement, misrepresent, conceal or withhold facts, or fail to report changes to establish or maintain eligibility for
energy assistance, your benefits may be denied, terminated or reduced. You are responsible for repayment of all monies, services and
benefits for which you were not entitled. Additionally, you may also be barred from program participation, criminally prosecuted and/or
otherwise penalized according to state and federal law.
Have you ever been determined to have committed an Intentional Program Violation (IPV)? YES NO If YES, in what
State?______
H. AUTHORIZATION
By signing this application, I am authorizing the Department of Health and Human Services to make any investigation concerning me or
any other member of my household which is necessary to determine eligibility for benefits received or to be received under programs
administered by the Division of Welfare and Supportive Services. I hereby authorize and consent to the release of any and all information
concerning me and/or my household members to the Division of Welfare and Supportive Services by the holder of the information
regardless of the manner or form held, including by, without limitation, wage information, information made confidential by law or
otherwise privileged under NRS 422A.342 or any other provision of law or otherwise. I authorize the Energy Assistance Program to
release information about my household, to include energy usage information, to the State of Nevada Housing Division, Weatherization
Assistance Program, for potential eligibility in weatherizing my residence. I hereby release the holder of such information from liability,
if any, resulting from the disclosure of the required information. I ACKNOWLEDGE THAT A REPRODUCED COPY OF THIS
AUTHORIZATION LEGALLY CONSTITUTES AN ORIGINAL COPY. Initials __________
If I am 60 years of age or older, I hereby consent to the disclosure of my identity and waive my rights as an older person to have my
identity kept confidential. I hereby release the holder of information from liability, if any, resulting from the disclosure of the required
information. Initials __________
I consent that the Division of Welfare and Supportive Services or its representatives may survey my energy usage, advise providers of
assistance grants, and status at the time of certification. I consent that the Division of Welfare and Supportive Services use Social
Security Numbers (SSNs) provided in this application to verify factors of energy assistance program eligibility, which may include
automated data exchange with the Social Security Administration.
I agree to notify the Energy Assistance Program of any changes in my household circumstances that may affect my benefits. I understand
failure to report changes may cause an overpayment which I would be responsible to pay back and could even be prosecuted by a court
of law. I swear I have honestly reported the citizenship of myself and anyone I am applying for.
I certify under penalty of perjury, my answers are true, correct and complete to the best of my knowledge and ability.
Print Name of Applicant:
Signature of Applicant:
Date:
Print Name of Other Adult Member(s) in Household:
Signature of Other Adult Member(s) in Household:
Date:
Print Name of Other Adult Member(s) in Household:
Signature of Other Adult Member(s) in Household:
Date:
WITNESS: (Use if applicant cannot read or write or is blind.) I have assisted with the completion of this application for
Energy Assistance. The information in this application has been read to the applicant and I have witnessed the above
signature.
________________________________________________
Print Name of Witness
________________________________________________ _________________________________
Signature of Witness Date
(Page 5 of 6) 2824 – EL (7/20)
Division of Welfare and Supportive Services
ENERGY ASSISTANCE PROGRAM
NOTICE OF RIGHTS AND OBLIGATIONS
PLEASE READ AND SIGN BELOW**** ****
A. You have the following RIGHTS:
1. No person will be discriminated against for any reason, e.g., race, age, color, religion, sex, disability, handicap (including
AIDS and AIDS related conditions), political belief or national origin, in any program administered by the Division of
Welfare and Supportive Services. When the Energy Assistance Program (EAP) pays another agency, institution or
person to provide EAP services to a household, the provider is not permitted to discriminate for any reason. Violations
of discrimination shall be promptly reported to the Energy Assistance Program office, the Division of Welfare and
Supportive Services Administrator, 1470 College Parkway, Carson City, Nevada 89706-7924, (775) 684-0500, the U.S.
Office for Civil Rights (OCR), Department of Health and Human Services, 50 United Nations Plaza, San Francisco,
California 94102, (415) 437-8310, TDD (415) 437-8311 or by calling toll free 1-800-368-1019.
2. You have the right to a conference if you believe you have been unfairly treated or a mistake has been made concerning
your eligibility for assistance. To request a conference, write or call the Energy Assistance Program.
3. You have the right to a hearing if you are not satisfied with the agency’s action affecting your assistance if you request
the hearing, in writing, within ninety (90) days of the agency’s action/decision, unless the sole issue for the agency’s
action/decision is one of state or federal law requiring automatic benefit adjustment. You have the right to a hearing if
your application is denied, acted upon erroneously, or not acted upon with reasonable promptness, or if your benefits
have been reduced.
4. You have the right to a mailed notice of decision telling you if you are eligible for program benefits and in what amount,
to whom payments will be made, and the approximate payment date(s); or a notice informing you that you are not
eligible for program benefits and why.
5. Program staff are required to:
• Inform applicants of the eligibility requirements for the program;
• Counsel on required documents; and/or
• Provide assistance to the applicant when needed.
B. You have the following OBLIGATIONS:
1. Notify the Energy Assistance Program within ten (10) calendar days of any of the following. Failure to do so may delay
processing your application, or result in denial of benefits or a reduction in benefits.
• Any change in your household income or household size (number of people residing in the household);
• If you change utility companies; or
• If you move anytime after submitting your application.
2. Respond to any requests for additional information needed to process your application within ten (10) calendar days.
It is your responsibility to ensure the requested materials are mailed or faxed early enough to meet the deadline provided
to you. The Energy Assistance Program is not responsible for lost or misdirected mail, or faxes. (Be sure your name
and SSN or UPI are on all documents/correspondence.)
3. Cooperate with the Energy Assistance Program in its efforts to secure all information necessary to determine eligibility
or benefits.
C. SPECIAL NOTE:
1. If you are applying for the Energy Assistance Program, you may receive help with your heating and/or electric bills.
BUT REMEMBER, YOU MUST KEEP PAYING YOUR BILLS WHEN THEY ARE DUE. If you do not pay
them, the company can charge more money for paying late. The utility company can even turn off your service and you
may be required to pay a deposit before they will turn your service on again. If you cannot pay your bill, contact the
utility company and try to make payment arrangements.
2. Persons found guilty of intentionally violating program rules will be ineligible for program participation for one (1) year
for the first violation, two (2) years for the second violation, and permanently barred from the program for the third
violation.
My signature below indicates I understand the Rights and Obligations as an applicant for the Energy Assistance Program.
Print Name of Applicant:
Signature of Applicant:
Date:
Print Name of 2
nd
Adult:
Signature of 2
nd
Adult:
Date:
(Page 6 of 6) 2824 – EL (7/20)
IF YOU ARE NOT REGISTERED TO VOTE WHERE YOU LIVE NOW,
WOULD YOU LIKE TO REGISTER TO VOTE HERE TODAY?
(Please check one)
YES
NO
If you do not check either box, you will be considered to have decided not to register to vote at this time.
The NATIONAL VOTER REGISTRATION ACT provides you with the opportunity to register to vote at this
location. If you would like help in filling out a voter registration application form, we will help you. The decision
whether to seek or accept help is yours. You may fill out the application form in private.
IMPORTANT NOTICE: Applying to register or declining to register to vote WILL NOT AFFECT the amount
of assistance you will be provided by this agency.
Signature
Date
CONFIDENTIALITY: Whether you decide to register to vote or not, your decision will remain confidential.
IF YOU BELIEVE SOMEONE HAS INTERFERED with your right to register or to decline to register to vote, or
your right to choose your own political party or other political preference, you may file a complaint with the Office
of the Secretary of State, Capitol Complex, Carson City, Nevada 89710.
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IMPORTANT NOTICE How to Apply for the Energy (State of Nevada, Department of Information Technology)

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