Fillable NYSERDA RESIDENTIAL FINANCING AND INCOME SCREENING APPLICATION (Energy Finance Solutions)

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NYSERDA RESIDENTIAL FINANCING AND INCOME SCREENING APPLICATION (Energy Finance Solutions)

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NYSERDA RESIDENTIAL FINANCING
AND INCOME SCREENING APPLICATION
VERSION 06.01.2020 – PREVIOUS VERSION WILL NOT BE ACCEPTED Page 1 of 7
SECTION A – APPLICATION REQUEST
This is not a contract for a loan, nor does it lock you into any commitment with a contractor. Applying for a loan will include a review of your
credit history. Final loan type, interest rate, and loan term will be based, in part, on a review of your clean energy project.
Application Type (select all that apply)
Loan Product (see below regarding interest rate determination) Incentive Product
Clean Energy Project Type (select all that apply)
Energy Efficiency Upgrades Solar Electric System Pellet Stove
Ground Source Heat Pump Air Source Heat Pump
Loan Type (All Loan Applicants Must Select One)
On-Bill Recovery Loan (If the project is ineligible, you will be considered for a Smart Energy Loan)
Smart Energy Loan
Loan Amount (All Loan Applicants Must Select One)
$5,000 or less $5,001 or more
Fee
information: No fee is required to apply. If approved, there is a $150 processing fee to prepare the loan documents.
This fee will be included in your loan unless you indicate here you would like to pay the fee back by check.
The
interest rate
for your loan will be determined based upon the household income of the installation property, location of the installation
property, manner of repayment (loan type), underwriting criteria, and project type. Household income information will be requested in Section
K. Visit
www.nyserda.ny.gov/All-Programs/Programs/Residential-Financing-Options/lmi-search
for additional information on household
eligibility and interest rates.
If you, the borrower(s), wish to forego the income screening of all installation property occupants, you may do so by opting out of the
household income screening. The borrower and co-borrower (if applicable) may still be required to submit income documentation for loan
underwriting purposes. Proceeding with the installation property household income screening may result in a lower interest rate for your
loan. Installation property households may also be determined eligible for a program incentive, which may reduce the amount of your loan.
Opt Out:
I/we, the borrower(s), wish to forego the installation property household income screening, and proceed with the loan at the
highest interest rate available for my installation type at the time my application is decisioned.
SECTION B – PROPERTY INFORMATION
Installation address where the clean energy improvement(s) will be made:
Street
Unit #
City
State
Zip
County
No. of Units (5+ does not qualify):
Single Family 2-Family Home 3-Family Home 4-Family Home Mobile Home
SECTION C – BORROWER INFORMATION
Last Name
First Name
Middle Initial
Jr./Sr./II/III
Former/Alternate Name
Date of Birth (mm/dd/yyyyy)
Social Security Number
Ext.
Secondary Phone
Ext.
Email Address
How are you associated with the installation property? Own Rent Other
Who resides at the installation property? Owner Tenant Other
If owner, how many years have you owned the installation property? _________________
Mailing Address (if different from installation address)
Unit #
City State Zip County
VERSION 06.01.2020 – PREVIOUS VERSION WILL NOT BE ACCEPTED Page 2 of 7
SECTION D – CO-BORROWER
A co-applicant is not required but may enhance your ability to meet the financing eligibility requirements.
Mr./Mrs./Ms.
Last Name
First Name
Middle Initial
Jr./Sr./II/III
Former/Alternate Name
Date of Birth (mm/dd/yyyyy)
Social Security No.
Primary Phone No.
Ext.
Secondary Phone No.
Ext.
Email Address
How are you associated with the installation property? Own Rent Other ________________
Who resides at the installation property? Owner Tenant Other ________________
If owner, how many years have you owned installation property? _________________
Mailing Address (if different from installation address)
Unit #
City
State
Zip
County
SECTION E – PROPERTY OWNER INFORMATION
Complete this section only if the property owner is different than the borrower or the co-borrower.
Mr./Mrs./Ms.
Last Name
First Name
Middle Initial
Jr./Sr./II/III
Former/Alternate Name
Date of Birth (mm/dd/yyyyy)
Social Security No.
Primary Phone No.
Ext.
Secondary Phone No.
Ext.
Email Address
Mailing Address (if different than installation address)
Unit #
City
State
Zip
County
Is Property owned by a legal entity (not a person)? Yes No
Entity Type: (Trust, Life Use, other legal entity)
If applicable, provide the entity name, signatory name, and signatory title of the individual authorized to act on behalf of the entity below.
Entity Name
Signatory Name
Signatory Title
SECTION F – PROJECT PARTNER INFORMATION
Contractor Name (if known)
Community Energy Advisor Name (if applicable)
VERSION 06.01.2020 – PREVIOUS VERSION WILL NOT BE ACCEPTED Page 3 of 7
SECTION G – ENERGY SUPPLIER INFORMATION
Electric Utility Name
Account Number
Name on Account
Indicate here if you are currently on a Deferred Payment Plan with your Electric utility.
Natural Gas Utility Name (if applicable)
Account Number
Name on Account
Indicate here if you are currently on a Deferred Payment Plan with your Natural Gas utility.
Indicate here if you purchase oil, propane, kerosene, wood pellets, coal or wood.
*Attach a copy of your most recent electric and gas (if applicable) utility bills indicating one of the borrowers is the account holder if applying
for an On-Bill Recovery Loan.
If you are a PSEG Long Island Customer, please answer the following questions:
How is your home heated? (example: propane)
Does your home currently have Central Air Conditioning, or will you be adding Central Air Conditioning as part of your Energy Efficiency
Project? Yes No
Are you completing a conversion to Natural Gas Service? Yes No
**PSEG Long Island Customers must also submit copy of PSEG Audit Completion in order to be income screened for incentives or reduced
interest rates on loan applications.
SECTION H – AUTOMATIC PAYMENT AUTHORIZATION
The Smart Energy Loan offers customers a choice to repay their loan via automatic payments from their checking or savings account. If
approved for the Smart Energy Loan, would you like to authorize automatic payments? Yes No (Please check one)
If yes, please complete the information below regarding the bank account from which you would like your loan payments to be debited.
NOTE:
You may choose to wait to provide your account information until your loan is approved; however, banking information must be
received prior to finalizing and signing your loan agreement. It is not necessary to include a copy of a voided check upon application
submission.
Account Type: Checking Account Savings Account
Bank Name
Bank Address
9-digit Bank Routing Number
(verify routing number with your bank)
Bank Account Number
The above-named Borrower(s) (“You” or “Your”) have authorized
NYSERDA’s loan servicer, Concord Servicing Corporation (“Us” or “We”)
or its successors or assigns, to withdraw the indicated monthly
automatic payment amount from Your account at the above-mentioned
financial institution on the payment due date for the purpose of making
payments on your Smart Energy Loan account.
The initial
correspondence from Concord Servicing Corporation will notify you when
your automatic payment is activated.
To revoke this authorization
please call
1-866-859-4403
at least
3
business days prior to your next
scheduled payment due date. You are responsible and liable for all
authorized transactions made under this automatic payment
authorization. We will not be liable for any fees your financial institution
may assess if you do not have sufficient funds in your account to cover
payment. All payments will be posted to your account on the statement
due date. If your due date falls on a weekend or holiday, your payment
will be posted the next business day. You understand that purposely
false or misleading information given may be considered fraud and
covered under applicable laws.
VERSION 06.01.2020 – PREVIOUS VERSION WILL NOT BE ACCEPTED Page 4 of 7
SECTION I – LOAN UNDERWRITING INCOME DOCUMENTATION
Income information and documentation is required for each borrower.
Please provide current regular sources and amounts of income in the
table below. If listing income from self-employment, business, rental, or farming income, list the net income after operating expenses. You
may meet the income documentation requirements by either providing tax returns, or by documenting current sources of income for each
borrower/co-borrower.
Social Security Numbers, Routing and Account Numbers, and any PINs may be blackened-out on these documents.
Name of Income Recipient
Income Type
(ex. Wages, Social Security, Pension, etc.)
Current Annual
Income Amount
Total
Total
Tax Return:
Provide a copy of the most recent Federal Income Tax Return (Form 1040, 1040A, or 1040EZ) for the borrower/co-borrower. If
one of the borrowers filed a joint return, but is not applying jointly, s/he must provide W-2 and 1099 statements instead of the tax return or
use the individual income sources option below. If earning rental/self-employment income, submit Schedule C, E, and F along with the tax
return. If you do not have rental/self-employment income, you do not need to provide the Schedules or Forms filed with the return. If you do
not have a copy of your return, you may request a transcript of your return be mailed to you free of charge by completing the IRS Form 4506-
T, or by going to IRS.gov and clicking on “Get a tax transcript”, or by calling 1-800-908-9946.
OR
Individual Income Sources:
If your current income is significantly different from the income on your last filed tax return, or if you have sources
of income not included on your tax return, provide documentation for each source of income listed in the table above using the example in
the table below. Please use additional pages if needed.
Provide the following documentation for each income source listed above:
Wages/Salary/Commissions
Copy of two most recent paystubs showing year-to-date gross earnings, or letter from
employer stating gross year-to-date earnings
Pension/Social Security
Copy of award letter for current year or copy of bank statement showing deposit
sources and amounts
401(k)/IRA/Interest Earnings Copy of brokerage/account statements showing regular pattern of distributions
Alimony Copy of divorce decree or court order that established the support
Self-Employment/Business Income/Rental
Income/Farming Income
Copy of most recent Federal Income Tax Return with Schedule C, E, or F, or profit &
loss statement for past 12 months. Alternatively, for rental income, you may also list
income as 75% of the gross annual leases for the property, and submit a schedule
listing the property units and the gross annual lease amounts.
SECTION J –LOAN CONSENT AND SIGNATURES
I understand that the energy savings numbers provided to me by my contractor are estimates only and are not guaranteed. If the estimated
savings are not achieved, or are less than what was estimated, my debt obligations may increase. Regardless of actual achieved savings, I
will still be obligated to make my loan payments.
(All borrowers must initial on the line below for application to be accepted)
_____________
initials
By signing below, I/we certify that all information provided on this application, including statements and documents submitted in connection
with this application, are correct and complete to the best of my knowledge. I understand that if I give false information on this application or
withhold information in order to make myself eligible for benefits that I am not entitle to, I can be prosecuted to the fullest extent of the law. I
understand that by submitting this application I am not guaranteed a loan and whether or not I will be provided a loan will depend, in part,
upon the number of applications received, the remaining funding available, and the priorities to be met by the program.
VERSION 06.01.2020 – PREVIOUS VERSION WILL NOT BE ACCEPTED Page 5 of 7
I acknowledge that NYSERDA has retained Energy Finance Solutions (“EFS”), a service offered by Slipstream Inc., to process this application
and underwrite my/our loan. I authorize EFS to obtain credit reports in connection with my/our loan request. I also authorize EFS to verify
records necessary to assure eligibility for my/our loan request. If necessary, I further agree to provide additional information to EFS to
underwrite my/our loan request.
I acknowledge that the energy efficiency improvements being made to the home, or installation of a renewable energy system, are designed
to reduce my energy costs or provide health and safety improvements, and my contractor will provide estimates of future energy cost savings
based on energy modeling, or the contribution of a renewable energy system, which may vary from the results I will realize. The estimate may
include assumed increases in future energy costs, which may not reflect actual future energy costs. These savings are not guaranteed by
either the contractor or NYSERDA. Incurring this loan to undertake these improvements may not result in the estimated reduction in energy
costs over time, based on additional factors that contribute to monthly energy usage and costs.
I acknowledge the interest rate for my loan will be determined based upon the income screening of the installation property household(s),
unless I have opted out of the income screening in Section A of this application. Opting out of the screening will result in my/our loan
application defaulting to the highest interest rate available through the NYSERDA Program for my installation type at the time my/our loan
application is decisioned.
I further acknowledge and agree that NYSERDA and EFS may share with and disclose to, orally and/or in writing, the project partner(s)
identified by me above, or as subsequently identified by me to EFS, the following information regarding this application: whether the
application has been pre-approved by EFS, and any additional items requested by EFS in order to complete my loan approval; whether the
application has been approved by EFS, and the approved loan amount so that my project partner(s) can proceed with scheduling the work;
and whether my application has been denied, so that the project partner(s) can determine if there is other financing available, and whether I
intend to proceed.
In addition, if this application is approved and NYSERDA makes the On-Bill Recovery Loan I have requested, I also authorize NYSERDA, its
loan servicer, and the utility providing my gas and/or electric service and their employees, contractors, and agents to share such information
concerning: my electric and/or gas utility usage and billing information; and the charges that are payable by me under the loan agreement
(note) that I will sign.
The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion,
national origin, sex, marital status, or age.
Whether or not the undersigned have elected to sign this document electronically, EFS, and or any subsequent holders of this document,
shall have the right to convert and store the manual signature electronically, and the undersigned consents to the use of the electronically
stored version in the same manner as an original signed copy.
I understand and intend that a legal signature is formed by entering my name on this and other documents provided to me, and by entering
my name on this and other documents provided in relation to this transaction I intend for my electronic signature to have the same force and
effect as my manual signature. If any of the parties do not wish to sign this document electronically, all must opt out together and request a
paper copy to sign manually.
By entering my name below, I am creating a legally binding signature and confirm that I agree and accept the electronic signature terms and
conditions.
Applicant’s Signature
Date
Co-Applicant’s Signature
Date
SECTION K – INCOME SCREENING FOR INTEREST RATE AND INCENTIVE
Special instructions for borrower(s) who occupy the installation property:
If you have already listed all of your household income in Section I, please identify in the table below if either borrower is a full-time student;
answer the question below the table regarding 1) number of people in the household; 2) HEAP, public assistance, or other services; and
complete Section L.
If you have opted out of the income screening in Section A of this application, do not receive HEAP or public assistance, and neither borrower
is a full-time student, you do not need to complete the remainder of this application.
If you have additional household members and/or income sources, please complete the remainder of the application.
If you do not occupy the installation property, please request the occupant(s) to complete the remainder of this, or a separate income
screening application.
VERSION 06.01.2020 – PREVIOUS VERSION WILL NOT BE ACCEPTED Page 6 of 7
Only complete this section if you occupy the installation property. If you are only using this application to apply for the household income
review, please also complete Sections B, E, F, and G above.
Information provided in this section will be used to determine your interest rate
and eligibility for an incentive to help pay for the installation of your clean energy project. Eligibility is based upon the total gross annual
income of each household unit that completes an income screening application. Installation properties of up to 4 units may apply. Additional
household units should complete a separate income screening application (one form per household unit).
Income-eligible applicants may qualify for the following incentives:
• An incentive for
energy efficiency upgrades
through the Assisted Home Performance with ENERGY STAR® Program. To learn more
visit
www.nyserda.ny.gov/assisted-home-performance
.
• An incentive for income-eligible homeowners for a
solar electric installation
through the Affordable Solar Program. To learn more visit
www.ny-sun.ny.gov/affordablesolar
.
• A rebate for the purchase of a
Pellet Stove
for income-eligible homeowners through the Pellet Stove Program. To learn more visit
www.nyserda.ny.gov/pelletstove
.
If
you need additional information, call 1-866-NYSERDA.
Income information and documentation is required. Complete the chart below listing all household members. Provide all types of current
gross annual income for all residents of the household, age 18 and over, who are not full-time students
. The borrower and co-borrower
should only list additional sources of income not noted in Section I, Loan Underwriting Income Documentation.
If listing income from self-
employment, business, rental income, or farming income, list the net income after operating expenses. Please use additional pages, if
needed.
Household Occupant
Income
Last Name First Name Age
Full-Time
Student
(Y/N)
Income Type
(ex. Wages)
Current Annual Income
Amount
Additional Borrower
Income
$
$
$
Additional Co-
borrower Income
$
$
$
Additional Household
Income Earner 1
$
$
$
Additional Household
Income Earner 2
$
$
$
List All Non-Income
Earning Household
Members
Are you currently eligible for, or have you received within the past 12 months, services through:
NYSERDA's EmPower New York Program, the New York State Weatherization Assistance Program, HEAP, SNAP/food stamps, or supplemental security
income. If your household receives any of these sources of income, please provide the service award letter in addition to the income documentation you may
be providing for the loan. If you are not applying for the loan, you do not need to provide any additional income documentation other than the award letter.
If
your household has not received these services, you may meet the income documentation requirements by either providing tax returns, or by documenting
current sources of income for each household member. Social Security Numbers, Routing and Account Numbers, and any PINs must be blackened-out on
these documents.
Refer to Section I for information on documenting income.
Total number of people in the household __________
VERSION 06.01.2020 – PREVIOUS VERSION WILL NOT BE ACCEPTED Page 7 of 7
L – INCOME-ELIGIBLE INCENTIVE CONSENT AND SIGNATURES
By Signing below, I/we certify that all information provided on this application, including statements and documents submitted in connection with this
application, are correct and complete to the best of my knowledge. I acknowledge that NYSERDA has retained Energy Finance Solutions (“EFS”), a
service offered by Slipstream Inc. (“Slipstream”), to process and underwrite my/our income qualification application. If necessary, I further agree to
provide additional information to EFS and Slipstream to underwrite my/our income screening application.
I further acknowledge and agree that NYSERDA and EFS may share with and disclose to, orally and/or in writing, the project partner(s) identified by
me above, or as subsequently identified by me to EFS, the following information regarding this application: whether the application has been pre-
approved by EFS, and any additional items requested by EFS in order to complete my income qualification application; whether the application has
been approved by EFS, and the approved incentive amount so that my project partner(s) can proceed with scheduling the work; and whether my
application has been denied, so that the project partner(s) can determine whether I intend to proceed.
I understand that my signature on this form gives permission for NYSERDA, or its designee, to verify records necessary to assure my program
eligibility. I understand that if I give false information or withhold information in order to make myself eligible for benefits that I am not entitled to, I
can be prosecuted to the fullest extent of the law.
I understand this application does not guarantee assistance will be granted but will be used in determining eligibility for the program. Whether or not
an eligible applicant will be provided assistance will depend in part upon the number of applicants received, the remaining funding available, and the
priorities to be met by the program.
Whether or not the undersigned have elected to sign this document electronically, EFS, and or any subsequent holders of this document, shall have
the right to convert and store the manual signature electronically, and the undersigned consents to the use of the electronically stored
version in the same manner as an original signed copy.
I understand and intend that a legal signature is formed by entering my name on this and other documents provided to me, and by entering my name
on this and other documents provided in relation to this transaction I intend for my electronic signature to have the same force and effect as my
manual signature. If any of the parties do not wish to sign this document electronically, all must opt out together and request a paper copy to sign
manually.
By entering my name below, I am creating a legally binding signature and confirm that I agree and accept the electronic signature terms and
conditions.
One household member listed in Section K is required to sign and date below. All income earning household members may sign and date
below.
Signature ________________________________________________
Date _________________________________
Signature ________________________________________________
Date _________________________________
Signature ________________________________________________
Date _________________________________
Signature ________________________________________________
Date _________________________________
Submit completed application to Energy Finance Solutions through one of the following methods:
Mail:
Energy Finance Solutions
431 Charmany Drive
Madison, WI 53719
Fax:
608-249-5788
Email: efs@energyfinancesolutions.com
Apply Online:
www.energyfinancesolutions.com
For more information, please contact Energy Finance Solutions (EFS):
Toll Free:
1-800-361-5663
or visit
www.nyserda.ny.gov
.
Note: Incomplete applications will not be processed
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Completed 21 March 2021

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