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This is not a loan application, nor does it lock you into any commitment with a contractor. If you wish to apply for a loan, please
complete the NYSERDA Residential Financing and Income Screening Application.
What are you applying for? Income Screening for Reduced Loan Interest Rate Incentive Both
Clean Energy Project Type (Select all that apply)
Energy Efficiency Upgrades Solar Electric System Pellet Stove
Solar Hot Water System Ground Source Heat Pump Air Source Heat Pump
Only complete this application if you occupy the installation property. Information provided in this application may be used to
determine the interest rate available to borrower(s) who submit a Credit Application for a loan to pay for the installation of a clean
energy project to the property you occupy. Information provided will also be used to determine eligibility for an incentive to further
help pay for the installation. Eligibility is based upon the total gross annual income of each household unit that completes an income
screening application. Installation properties of up to four units may apply. Each household unit should complete a separate income
screening application.
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
An incentive for income-eligible homeowners for a
solar electric installation
through the Affordable Solar Program. To learn
more visit
A rebate for the purchase of a
Pellet Stove
for income-eligible homeowners through the Pellet Stove Program. To learn more
If you need additional information, call 1-866-NYSERDA.
SECTION B PROPERTY INFORMATIONInstallation address where the clean energy improvement(s) will be made.
Mr./Mrs./Ms. Last Name First Name
Primary Phone No. Ext. Secondary Phone No.
Ext Email Address
Unit #
Select One: Owner Occupied Rental Unit
No. of Units (5+ does not qualify):
Single Family 2-Family Home 3-Family Home 4-Family Home Mobile Home
SECTION C – PROPERTY OWNER INFORMATION Complete this section only if the property owner is different
than the applicant.
Last Name First Name Middle
Ext. Secondary Phone No. Ext. Email Address
Mailing Address (if different than installation address)
Unit #
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Contractor Name (if known)
Community Energy Advisor Name (if applicable)
Electric Utility Name
Account Number
Name on Account
Electricity is paid by: Owner Tenant
Natural Gas Utility Name (if applicable)
Account Number
Name on Account
Heat is paid by: Owner Tenant
Indicate here if you purchase oil, propane, kerosene, wood pellets, coal, or wood.
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.
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
If listing income
from self-employment, business, rental, or farming income, list the net income after operating expenses. Please use additional
pages, if needed.
Household Occupant
Last Name First Name Age
Income Type
(ex. Wages)
Current Annual
Household Income
Earner 1
Household Income
Earner 2
Household Income
Earner 3
Household Income
Earner 4
List All Non-Income
Earning Household
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. 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.
Tax Returns:
Provide a copy of the most recent Federal Income Tax Return (Form 1040, 1040A, or 1040EZ). If the borrower and co-borrower are
providing tax returns to document income, all additional household members must also document income by providing tax returns. This option is
only available if all household members required to file a return did file a return. If earning rental/self-employment income, submit Schedule C, E
Total number of people in the household __________
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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 and clicking on “Get a tax transcript”, or by calling 1-800-908-9946.
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.
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.
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
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
Signature ________________________________________________
Date _________________________________
Signature ________________________________________________
Date _________________________________
Signature ________________________________________________
Date _________________________________
Signature ________________________________________________
Date _________________________________
Submit completed application to Energy Finance Solutions through one of the following methods:
Energy Finance Solutions
431 Charmany Drive
Madison, WI 53719
For more information, please contact Energy Finance Solutions (EFS): Toll Free: 1-800-361-5663 or visit