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home eneru1 Home Energy Plus Application (Brown County Information Services)

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BROWSE BROWN COUNTY INFORMATION SERVICES (WI) FORMS

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1
STATE OF WISCONSIN
DEPARTMENT OF ADMINISTRATION
DIVISION OF ENERGY, HOUSING AND
COMMUNITY RESOURCES
DOA-9549 (R06/2019)
HOME ENERGY PLUS PROGRAM
http://homeenergyplus.w i.gov/
Home Energy Plus Application
For Office Use Only – shaded areas to be completed by agency
Application Date (mm/dd/ccyy): Worker Number:
Withdrawn
Outreach Type: Local Agency Alternate Site ____________________________ Home Visit Mail Phone
Identification Verification: Driver’s license Government issued ID card
Identification verified by:
Employer’s ID card Student ID card Other:
NOTE: First time applicants are required to provide a photo id in person. The agency will contact you for this and social
security numbers for all household members.
This form is authorized under Wisconsin State Statute 16.27(2)(a). All information on the application is required in order to determine
eligibility for benefits under the Wisconsin Home Energy Assistance Program and the Wisconsin Weatherization Assistance
Program. Collection of your Social Security number is not prohibited by federal law and is required for tracking applicant benefits
granted by this program. By providing application information, you are authorizing the Wisconsin Department of Administration and
its authorized agents to verify the data provided against federal, state, county, energy provider, employer and landlord databases or
records. The information collected on this form may be disclosed to energy programs operating under the Wisconsin Public Benefit
Program Authority or Wisconsin Public Service Commission Approval, and may be used for the purposes of referral, research,
evaluation, and analysis.
1. Territory (County or Tribe) in which you live:
Person ID (This number is provided by the Program):
2. First Name:
Middle Initial:
3. Alias First Name (if applicable): Alias Last Name (if applicable):
4. Birth Date (mm/dd/ccyy):
5. Gender:
M F
6. Primary Phone Number:
( )
Home Work Cellular Contact
Secondary Phone Number:
( )
Home Work Cellular Contact
7. Email address:
8. Preferred method of household communication: Primary Phone Email Mail Text Message
9. Housing type you live in
:
Single family house
For Office use only: Ineligible Dwelling
2 to 4-unit building (including Condos) – Number of units/apartments in your building:
Apartment or multi-unit building (including Condos) – Number of units/apartments in your building:
Mobile home
Rooming house, motel, hotel, YMCA or YWCA
Other (describe)
10. Mailing Address (if different than residence address):
Address
City
State
Zip
11. Residence Address (must complete):
Address
City
State
Zip
home
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2
12. Own or rent your residence:
Own Rent - If rent, provide the following information (landlord information is required):
Management Company or Business Name (if applicable):
Point of Contact or Landlord Name:
Landlord Email Address:
Landlord Phone Number:
( )
Landlord Address:
City:
State:
Zip:
13. Identify the number of rooms in your residence:
Worker completes total number of rooms: _______
Living Room Dining Room
Kitchen Family Room
Number of Bedrooms Den/Office
List any other rooms:
Do not count bathrooms, unfinished basements, laundry rooms, entryways, hallways, unheated attics and porches or closets
Guardian/Representative Address:
City:
State:
Zip:
OR: List name of someone you are authorizing to discuss your application with who is not listed as a guardian or
designated representative: Relationship:
14. Select the response that best describes your living arrangement as of the date of this application:
Live in a group home, half-way house, Community Based Residential Facility (CBRF) or foster home
Live in a nursing home
Live in a government institution or prison or jail
Are currently in a homeless situation moving to a permanent residence
None of the above
15. Do you receive rental assistance (Section 8 or other government assisted housing)? Yes No
16. Is there a guardian or designated representative? Yes No If yes, complete representative information:
Authorization of Representative
Legal Guardian
Power of Attorney (POA)
Protective Payee
Guardian/Representative Name:
Guardian Phone Number: ( )
17. Are you (the applicant case head) a student under the age of 25 and enrolled at least half-time in an institution of higher learning?
Yes No
If yes, check any of the following conditions that meet your situation:
Currently working twenty or more hours per week making at least minimum wage
Financially responsible for a child under age 18 who is living with you
Physically or mentally disabled (Verification needed from government program)
Receiving Unemployment Compensation (UC) benefits resulting from TAA / NAFTA (must be a full-time student)
Receiving TANF or W-2 Benefits
Spouse lives with you who is not a student
None of the above apply
18. Applicant’s Ethnic Group (check one):
American Indian or Alaskan Native
Hispanic
Not Reported
Asian or Pacific Islander
White, not of Hispanic origin
Black, not of Hispanic origin
Other
19. Is anyone in the household under the age of 18 and related to any adult household member? Yes No
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20. Household Members:
Identify the preferred household language:
If preferred household language
is not English, list an English-speaking household member or representative who can answer
application
questions. (Completing this field is providing authorization for the program to discuss your application with this person.)
Name:
Phone Number:
( )
• List every person who lives at your residential address
today
• Worker will contact you for Social Security numbers for first
time applicants and new household members
• Line 1 must be the person listed on page 1 (date of birth
and gender must match information entered on page 1)
Name
Instructions at bottom of page are related to these
fields below by number indicated:
Worker
initials
Birth Date
mm/dd/ccyy
Gender
1
:
(M)ale, (F)emale
Is this person a U.S.
Citizen?
Is this person
disabled?
Food Share
2
Military Service
3
Is this a child with
shared placement?
4
Citizenship
5
(Office use only)
Enter “Y” for Yes and “N” for No
1.
Person from Field 2 (Page 1) must be listed here.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
1
Indicate the gender the individual most closely identifies with.
2
Enter “Y” in the box for FoodShare if that person received FOODSHARE IN ALL OF THE PREVIOUS 3 MONTHS to the date of this
application.
3
Enter “Y” in the box for Military Service, if that person is serving or has ever served in a branch of the United States military as Active
Duty, Reserve, or National Guard. (Army, Navy, Air Force, Marine Corps, Coast Guard)
4
List all children living in your household that are in a minimum of 50% shared placement. Verification of child placement (ex. copy of
court order) is required when children are living in a shared physical placement living arrangement.
5
The office worker will enter “C”, “E”, or “I” in the box for Citizenship, if that person is a U.S. (C)itizen, (E)ligible Non-Citizen, or
(I)neligible Non-Citizen. Worker who completed this box should initial at the top of the column.
4
(A) Alimony Received
(GF) Gift/donations
(SSDI) Social Security Disability Insurance
(CS RECD) Child Support Received
(GV) Government Relief or Disaster
(SSI) Supplemental Security Income
(CS Paid) Child Support Paid
(LC) Land Contract Payment
2
(T) TANF/W2
(CTS) SSI Caretaker Supplement
(O) Other
(TR) Tribal per Capita
1
(DL) Disability Long-term
(P) Pensions, Annuities, and IRAs
1
(UC) Unemployment Compensation
3
(DS) Disability Short-term
(R) Rental Income
1
(V) Veterans Benefits
(D) Dividends/Interest
1
(SE) Self-Generated Income
1
(W) Wages & Tips
3
(G) Gambling/Lottery/Bingo
(SP) Spousal Impoverishment
(WK) Workers Compensation
(GR) General Relief
(SS) Social Security
Instructions:
List all household gross income in the chart below. Enter income code above in the income type column and where that
income comes from in the income source column
. REQUIRED: Proof of gross income received is needed for each income listed below.
Household Member’s
Name
Income
Type
Income
Source
4
Previous three months income
3 Month
Total
Verification
Item
Month 1
______
Month 2
______
Month 3
______
Example:
John Doe
W
ABC Corporation $1,072.60 $978.40
$1,278.25
Do not
complete
Do not
complete
Total 3 Month Household Income
1
This income is based on the average of the prior 12 months of income. A copy of the tax return will need to be provided to complete
this application.
2
Only the interest income received is counted. A copy of the amortization schedule or the 1099 issued for tax purposes will need to be
provided to complete this application.
3
If the household member is a seasonal employee (a person whose main source of income is earned in less than 12 months of a
calendar year), the annual income must be provided for both wages and unemployment compensation received in the prior tax year.
Copies of form W2 and 1099 will need to be provided to complete this application.
4
Source: i.e. wages – include name of employer such as Lloyds Market, if self-employment include type of business or business name,
if pension include the payee of the pension, interest and dividends include the payee of this income.
21.
Income:
Is your ho
usehold a zero income household? Yes No
N
ote: A zero income household has no sources of income, either earned or unearned in the previous three months. If your household
has no income
during this time period, your signature on the client certification page may need to be notarized.
Income Types:
If anyone in the household is paying court-ordered child support (CS Paid) include that in the income below. Cash jobs
should be reported as Self-Generated Income.
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22. Energy Usage: Complete every section of energy usage – continued on next page
*A vendor must be entered showing who provides electricity to this dwelling even if electricity is included in rent or a separate payment
is made to landlord.
Primary Heat Source: Select one:
Electric Heat Fuel Oil Natural Gas Propane Wood or Other
Select how the fuel bill is paid (check only one):
Directly pay the bill sent from the energy supplier (Must complete account information)
Rental payment includes the energy in the monthly rent payment (not government assisted housing)
Separate payment is made to the landlord, mobile home park owner or no direct account with a vendor
Do not pay: energy included in the monthly rent when residing in government assisted housing or renters who pay neither rent or
heating/electric costs because of an in-kind arrangement
Is this account in a household member’s name? Yes No
If no, the account is in the name of: A Deceased Spouse A Protective Payee Other
Name on Account:
Is this meter shared with another dwelling unit? Yes No
Is there business or recreational use on this account (including farm, other self-employment, pool or hot tub)? Yes No
Vendor Name:
Vendor Number (office use):
Account Number:
Annual Fuel Costs:
Electric (Non-Heating): If your primary heat source (above) is electric, do not complete this section.
Select how the fuel bill is paid (check only one):
Directly pay the bill sent from the energy supplier (Must complete account information)
Rental payment includes the energy in the monthly rent payment (not government assisted housing)
Separate payment is made to the landlord, mobile home park owner or no direct account with a vendor
Do not pay: energy included in the monthly rent when residing in government assisted housing or renters who pay neither rent or
heating/electric costs because of an in-kind arrangement
Is this account in a household member’s name? Yes No
If no, the account is in the name of: A Deceased Spouse A Protective Payee Other
Name on Account:
Is this meter shared with another dwelling unit? Yes No
Is there business or recreational use on this account (including farm, other self-employment, pool or hot tub)? Yes No
Vendor Name*:
Vendor Number (office use):
Account Number:
Annual Fuel Costs:
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6
Additional Energy Account Information – answer the following questions regarding the household energy situation.
These answers will not affect your benefit amount but must be answered
Primary Heat Source:
If your primary heat source is natural gas or electric, have you received a past due or disconnect notice within the last 90 days?
Yes No Does not apply
If your primary heat source is propane or fuel oil, does your tank currently have equal to or less than 20% of fuel remaining?
Yes No Does not apply
Hot Water: Identify fuel type that heats the water in your home:
Electric Fuel Oil Natural Gas Propane Wood or Other None
Supplemental Heat Source (Do you use additional heat sources such as fireplace, wood burner, space heaters, or other alternate
heating type from the primary heat)
:
Identify
, if any, what supplemental heat is used in your home (select only one):
Electric Heat Wood or Other (Specify other) None
Air Conditioning:
Identify
the method used to cool your home (select only one): Central Air Wall/Window Unit A/C None
PLEASE SIGN PAGE 7
Proof of income is required to complete the application
Case Notes
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7
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 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 where I applied.
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, 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.
Applicant Signature
Date (mm/dd/ccyy)
FOR OFFICE USE ONLY
Agency Worker Signature
Date (mm/dd/ccyy)
I certify that I have verified the information on this application in accordance with Home Energy Plus policies and to the best
of my knowledge this information is complete and accurate. I further certify that I do not have a personal relationship to any
individual listed on this application in accordance with the Home Energy Plus Conflict of Interest Policy.
This application can be made available in alternate formats to individuals with disabilities upon request.
Person ID:
8
NOTE: Paper applications must be mailed to the local agency.
If the local agency address was not provided, you can obtain the correct mailing address for your
local agency from:
http://homeenergyplus.wi.gov/
Click on the ‘Where to Apply’ tab and select the county or tribe where you live.
Agency: Attach a mailing sticker here with correct mailing address for application to be submitted
---------------------------------------------------------------------------------------------------------------------------------------
Please tell us how you heard about the energy assistance program this year:
Insert in my utility bill
Bus Ad
Phone Call from Agency
Email from Agency
Mailed notice from Agency
Website (Identify Site)
Radio (Identify Radio Station) TV News
(Identify TV Station)
Notice in local paper or mailer
(Identify paper or mailer)
Energy Assistance Flier
(Where did you get the flier)
Other
(Identify the source)
DID YOU SIGN PAGE SEVEN?
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home eneru1 Home Energy Plus Application (Brown County Information Services)

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Completed 17 July 2020

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