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and F along with the 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 transcription of your return to be mailed to you free of charge by completing 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 of income for each individual listed in the table above per the table below.
Wages/Salary/Commission
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.
G – 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”); services 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 F 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
608-249-5788
efs@energyfinancesolutions.com
431 Charmany Drive
Madison, WI 53719
For more information, please contact Energy Finance Solutions (EFS): Toll Free: 1-800-361-5663 or visit www.nyserda.ny.gov.
