Certification Page
Read each item on this page before signing the application.
If you do not understand any item, ask the worker for assistance.
1. I understand I am responsible for providing all required information within 30 days of the date of this application or the
application is void and will be denied. I may reapply but a new application will be required.
2. I understand I am responsible for reporting the names of all persons living at my address and the Social Security number and
income of all persons in my household. Collection of Social Security number is not prohibited by federal law and is a required
data element for tracking applicant benefits granted by this Program. Failure to provide this information will result in delayed
processing of my application and the inability to determine benefit amounts.
3. I understand I am responsible for using the payments I receive to pay for the heating/electric costs for the residence listed in
my application or for paying the heating/electric costs for any future permanent residence I may move to in Wisconsin.
4. I understand I have the right to apply for Energy Assistance benefits and to receive either a payment or letter of explanation
within 45 days from the date the application process is completed. I understand that the payment or letter of explanation may
be delayed depending on when the Program year begins and/or when payments are being processed.
5. I understand I have the right to request a fair hearing within 15 days after receiving a notification letter if I believe my Energy
Assistance application has not been processed timely, has been incorrectly denied, or my payment is incorrect. I may also
request a fair hearing if I have not received payment or explanation. I may ask for a fair hearing by contacting the local office
that processed my application because I applied directly to their office or submitted an online application.
6. I understand I have the right to file a complaint if I believe I have been discriminated against in any unlawful way. I may file a
complaint by contacting the authorized person within my county or tribe.
7. I understand that by providing application information I am authorizing the Wisconsin Department of Administration and its
authorized agents to verify the data provided against federal, state, county, energy provider, water utility, employer and
landlord databases or records.
8. I understand that by providing the account numbers for my household energy supplier(s) I am authorizing the energy
provider(s) to provide details about the account and energy use to the Wisconsin Department of Administration for the
purposes of eligibility determination of this and future applications, benefit determination, and program evaluation and analysis
including before and after receiving any weatherization services.
9. I understand that the rights, requirements, and authorizations I certified to on this application may also apply to multiple heating
seasons, crisis, and furnace applications, when supplemental benefits are issued, and to outreach activities.
10. I understand the information collected on this form may be disclosed to energy programs operating under the Wisconsin Public
Benefit Program Authority, Wisconsin Public Service Commission Approval, or other programs administered by the State of
Wisconsin and may be used for the purposes of referral, research, evaluation, and analysis.
11. I understand if eligible for energy assistance benefits, I may be referred to other residential weatherization and/or energy
programs. I authorize the weatherization agency to provide weatherization services to my residence. If I am not the owner of
the residence, I authorize the weatherization agency to contact my landlord and I will cooperate with the agency providing
weatherization services.
I certify that the information on this application and all information given in connection with this application are true and complete
statements of facts. I further certify that I have read and understand the statements above. I understand that I may be required to
provide proof of any information on this application and that giving false information will invalidate this application, require the return of
any benefits received and possibly subject me to criminal prosecution. By typing my name in the ‘Applicant Signature’ field, I indicate
that I am the person named, and this entry is the legal equivalent of a manual/handwritten signature. I further understand that I may
print out the document and sign by hand.