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PROGRAM APPLICATION Alternatively, if you are in need

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PROGRAM APPLICATION
The CARE Program is an energy efficiency upgrade program
administered by Energy Outreach Colorado, a nonprofit committed to
ensuring that all Coloradans can afford their home energy needs. In
partnership with your utility provider and a network of local contractors
and nonprofits, the CARE Program can offer FREE energy efficiency
upgrades to households that are at or below 80% of the area median
income.
If you are interested in the CARE Program, please return a completed
application, including the required income verification documentation,
to Energy Outreach Colorado via the email, fax, or mailing address on
the following page.
If you are approved for the CARE Program, you will receive a free
home energy audit to determine what work your home will need,
followed by the work being completed by our trusted contractors. The
scope of work may include the following: LED light bulbs, Energy Star
refrigerator, air sealing, insulation, mechanical systems replacement/
tune-up, and more.
Questions? Email CARE@energyoutreach.org or call 303-226-5061.
Alternatively, if you are in need of utility bill payment assistance or
are interested in LEAP, please call 1-866-HEAT-HELP for more
information.
ADDRESS INFORMATION
HOUSEHOLD INFORMATION
APPLICANT INFORMATION
Apartment / Condo
Own
Mobile HomeHouse / Duplex
Rent*
APPLICATION CONTINUES ON REVERSE
Full Name ____________________________________________________ Email Address _______________________________________
Primary Phone # ______________________________________________ Date of Birth _________________________________________
With Disability ______Adults ______ Children ______
Number in Household (Enter ALL in household):
Physical Address and Mailing Address the same?
Physical Address _______________________________________________________________________________________ County ____________________
City _______________________________________________________________ State _____________________________ Zip _______________________
Mailing Address _______________________________________________________________________________________ County ____________________
City _______________________________________________________________ State _____________________________ Zip _______________________
Housing Type:
* If household is a rental, the Landlord MUST sign Landlord Authorization page.
Have you received help paying your utility bill:
NoYes
Through LEAP or another program?
Other Program _______________________________________________________________LEAP
Elderly ______
AGENCY
CONTACT INFORMATION
Who referred you to the program?
______________________________________________________________
Gender Identity: Female Male Non-Binary Prefer Not To Say
Employment Status: Full Time Part Time Unemployed Retired Other
Is anyone in your household: Disabled? Yes No
A veteran? Yes No
Race: American Indian/Alaska Native Asian Black/African American White/Caucasian
Hispanic/Latino Native Hawaiian/Pacific Islander Other _________________________________________________
Housing Status:
Townhome
HOUSEHOLD INCOME
APPLICATION SUBMITTAL
PROGRAM REQUIREMENTS
1. EXISTING HOME CONDITIONS AND MECHANICAL EQUIPMENT MUST MEET PROGRAM SPECIFICATION REQUIREMENTS TO BE ELIGIBLE FOR ENERGY EFFICIENCY UPGRADES.
2. ALL DWELLINGS AND SPACES INSIDE THE DWELLING MUST BE ACCESSIBLE AND PROVIDE SAFE WORKING CONDITIONS FOR THE INSTALLATION CONTRACTORS. 3.
ENERGY OUTREACH COLORADO’S ACCEPTANCE OF A SUBMITTED APPLICATION DOES NOT GUARANTEE THAT THE CUSTOMER OR MEMBER’S HOME WILL RECEIVE ENERGY
EFFICIENCY UPGRADES TO THE HOME. 4. ENERGY OUTREACH COLORADO AND ALL OF THE CARE PROGRAM UTILITIES RESERVE THE RIGHT TO CONDUCT AN ON-SITE
INSPECTION OF THE FUNDED ENERGY EFFICIENCY MEASURES. THE CUSTOMER OR MEMBER AGREES TO PROVIDE REASONABLE ACCESS TO INSPECT THE INSTALLATION.
ON-SITE INSPECTIONS MAY BE PERFORMED UP TO ONE YEAR AFTER THE INSTALLATION DATE OF THE ENERGY EFFICIENCY MEASURES. 5. ENERGY OUTREACH COLORADO
AND ALL OF THE CARE PROGRAM UTILITIES ARE NOT RESPONSIBLE FOR THE PROPER DISPOSAL/RECYCLING OF ANY WASTE GENERATED AS A RESULT OF THIS PROJECT;
ARE NOT LIABLE FOR ANY DAMAGE CAUSED BY THE OPERATION OR MALFUNCTION OF THE INSTALLED EQUIPMENT; AND DOES NOT GUARANTEE THAT A SPECIFIC
LEVEL OF ENERGY OR COST SAVINGS WILL RESULT FROM THE IMPLEMENTATION OF ENERGY EFFICIENCY MEASURES OR THE USE OF PRODUCTS FUNDED UNDER THESE
PROGRAMS. 6. APPLICANTS WILL NOT BE ALLOWED TO SKIP ELIGIBLE ENERGY EFFICIENCY MEASURES THAT ARE DEEMED TO BE COST EFFECTIVE. INSULATION, AIR
SEALING, AND LOW COST MEASURES MUST BE ADDRESSED BEFORE THE REPLACEMENT OF MECHANICAL EQUIPMENT CAN BE CONSIDERED.
Aid to the Blind (AB)
Aid to the Needy Disabled (AND)
Supplemental Nutrition Assistance Program (SNAP)
Old Age Pension (OAP)
Temporary Aid to Needy Families (TANF)
Social Security Income (SSI)
Social Security Disability Income (SSDI)
Supplemental Security Income (SSI)
Women, Infants, and Children (WIC)
Section 8 Housing
Household Assistance
You will AUTOMATICALLY qualify for the CARE program if you are currently recieving or enrolled in any of these benefits:
LEAP (Utility Bill Assistance)**
Fax
(303) 825-0765
Questions
(303) 226-5061
Email
care@energyoutreach.org
Applicants may submit their completed and signed applications to EOC or your local CARE organization.
Mail
Energy Outreach Colorado
Attn: CARE Program
225 E. 16th Avenue, Suite 200
Denver, Colorado 80203
APPLICANT AUTHORIZATION
Signature of Applicant Date
I certify that the information given on this application and in any other supporting documentation is accurate and true. I release my utility provider and
Energy Outreach Colorado of any and all liability for supplying or requesting such information. I release EOC to provide information for additional services.
Additionally, if work is approved to proceed, I will assure that an adult will be present during any scheduled work inside my home.
X
Proof of benefit from above list Most recent income (3 most recent paystubs)
Most recent Tax Return-IRS Form 1040*
Wages or Tax Statement W-2*
Retirement Benefits Letter
Letter from Employer
Annual Household Income Pre-Tax (entire household income must be represented): $ _______________________________________________________
Required Income Verification Documentation
Applicant MUST submit one of the paperwork options below with the completed application.
* Please remove Social Security Number from documents
** If you are currently receiving LEAP benefits, or enrolled in the current program year, no Income Verification Documentation is needed.
Electric Utility Provider ________________________________________________ Account # ___________________________________________________
Natural Gas or Propane Utility Provider __________________________________ Account # ___________________________________________________
CURRENT ENERGY PROVIDERS
You can find this information on your utility bill. This information MUST be provided and accurate in order to process the application and receive services.
AGENCY
CONTACT INFORMATION
Utility Account Holder’s Full Name ______________________________________ Relation to Applicant _________________________________________
OFFICE USE ONLY
Household Income: ____________________ Referral Program: ____________________
Pre-Approved:
NoYes
Houshold Assistance and Income Verification Documentation not requred if income is pre-approved through a referral program.
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Completed 17 November 2020

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