Individual EnergyUnited Application

Please Note:

APPLICANTS MAY SUBMIT ONLY ONE APPLICATION EVERY SIX MONTHS.

If you complete this form prior to six months from your last application, unfortunately, it will not be considered for a grant.

Documentation Needed

Before proceeding with this application, please be sure to have the following documents ready to upload. You will not be able to complete the application without these documents.

1. Verification of your most recent monthly income (for all in the household) and all current household bills.
2. A copy of pages one and two of your most recent Federal and State tax returns. W-2 forms, pay stubs, or 1099’s will not be accepted in place of tax returns.
– Federal and State tax returns are required for each person in the household who files
3. Proof of Social Security income or a statement of disability from your physician.
4. Please provide documentation to outline grave need based on major life event (examples: proof of major life event, fire accident report, unemployment document, etc.).
5. If you are requesting assistance with items other than monthly bills, i.e. house repairs, etc., please submit at least two detailed estimates with your application. Estimates must be from different vendors for the same item(s) or work with the same materials and labor stated separately on each estimate. Applications with only one estimate will not be considered.

Application Due Dates

All applications are due by the 25th of the month to be considered the third Tuesday of the following month. Any applications that are received after the 25th will be considered two months later.

Note: Any additional documents provided after the application is submitted will not be reviewed.

Notable Information

The information obtained in this application is solely for the purpose of determining qualification for a grant from the EnergyUnited Foundation, Inc. and will be kept in strictest confidence. The person signing this application warrants that the information provided is true and complete. EnergyUnited Foundation, Inc. is authorized to make all inquiries deemed necessary to verify the accuracy of the statements made herein. Any deliberate falsehoods detected will result in the denial of the assistance application.

To receive assistance from the Foundation, you do not have to receive electric power from EnergyUnited, but you must reside within EnergyUnited’s electric service area.

Funding Criteria

The EnergyUnited Foundation, Inc. Board of Directors shall disburse funds donated by members of EnergyUnited on behalf of individuals and households who are suffering unusual and/or unexpected problems and are in grave need of assistance. Grants may be used to pay for items such as shelter, utility bills, emergencies, and other humane needs. Grants ARE NOT awarded for school tuition and fees, medical bills or business related expenses.

APPLICANTS MAY ONLY SUBMIT ONE APPLICATION EVERY SIX MONTHS.

Disbursements are limited to $5,000 within a 12 month period for individuals and $10,000 within a 12 month period for households.

To ensure confidentiality, decisions made by the EnergyUnited Foundation Board of Directors will NOT be discussed with anyone. Reasons for Board decisions will not be given to anyone, including the applicant, if the request is granted or denied.

You will be notified if your grant is approved or denied. If approved, you will be asked to provide current invoices so your approved bill can be paid directly to the vendor.

Location

County of Residence:

Zip Code:

Applicant Information

Name (First and Last)

Email Address

Is your physical address different than your mailing address? (we need a physical address if different than mailing address)

Yes

Street (Mailing Address)

City (Mailing Address)

State (Mailing Address)

Zip Code (Mailing Address)

Street (Physical Address)

City (Physical Address)

State (Physical Address)

Zip Code (Mailing Address)

Phone

Other Phone Number (if applicable)

Last 4 of SSN

Date of Birth (MM/DD/YYYY)

Marital Status

Employer Information

Are you currently employed?

YesNo

If not currently employed, are you receiving (check all that apply)

SSDSSIUnemployment IncomeOther

If other, please specify

Employer (Company Name)

Employer City

Employer State

Hours Worked Per Week

Hourly Rate of Pay

Former Employer (Company Name)

Last day worked:

Hourly Rate of Pay at Previous Job

Hours Worked Per Week at Previous Job

Persons Living in the Home

List all family members that live in the home below.
Please List: Name, Age, Date of Birth, Relationship to Applicant, and Employer / School

Family Member Info:

Salesforce Info

Program ID

Record Type ID

Assistance Requested

Please check categories that you are requesting assistance:

HousingUtilitiesHumane Needs – including critical home repairs

Amount Requested (past due bills or detailed estimates are required to document amount requested.)

Include specific use of funds, please give detailed response but be as brief as possible. (If approved, the Foundation pays bills. We do not give direct cash grants).

Attach Supporting Documents for Humane Needs (attach two estimates here)

Attach 2nd Estimate Here

Explain your grave need or emergency situation. Why are you unable to pay for this/these items yourself?

Please provide documentation to outline grave need based on major life event (examples: proof of major life event, fire accident report, unemployment document, etc.)

Household Income

Type(s) of Income Received for Entire Household. Check all that Apply:

Salary / Monthly Income	Medicare / Medicaid
Disability	Retirement
Food Stamps	Work First
SSI	Housing Assistance
Unemployment	Other Pensions
Workers Compensation	Pell or Educational Grants
Other

Please use numbers only for below fields, do not use $ or other characters.

Salary – Monthly Gross Income

Person Earning Income

Net Pay – Monthly Take Home Pay

Person Earning Income

Medicare or Medicaid (check one or both)

MedicareMedicaid

Person Receiving Medicare / Medicaid

Type of disability received:

SSDVA

Person Receiving Disability

Retirement

Person Receiving Retirement

Food Stamps / SNAP

Person Receiving Food Stamps / SNAP

Work First

Person Receiving Work First

SSI

Person Receiving SSI

Amount of Housing Assistance

Person Receiving Housing Assistance

Unemployment (Monthly Amount)

Person Receiving Unemployment

Other Pensions

Person Receiving Pensions

Workers Compensation

Person Receiving Workers Compensation

Pell or Educational Grants

Person Receiving Pell or Educational Grants

Any Other Income

Person Receiving Other Income

Total Monthly Household Income (do not include food stamps)

Total Cash Held in Hand/Checking Accounts/Savings Accounts/Stocks, etc.)

Monthly Expenses

What type of monthly expenses do you have? Check all that apply:

Mortgage / Rent	Electricity
Water / Sewer	Home Heating Oil or Gas
Car Payment	Car Insurance

Do you rent or own your home?

RentOwn

Please use numbers only for below fields, do not use $ or other characters.

Mortgage / Rent Amount Current

Mortgage / Rent Amount Past Due

Electricity Current Month

Electricity Past Due Owed

Water/Sewer Current

Water/Sewer Past Due Owed

Heating Oil / Gas Current

Heating Oil / Gas Past Due Owed

Car Payment Current

Car Payment Past Due Owed

Car Insurance Current

Car Insurance Past Due Owed

Total Monthly Expenses

Total Amount Overdue

Attachments

Attach Copy of Mortgage / Rent Statement

Attach Copy of Electric Bill

Attach Copy of Water / Sewer Bill

Attach Copy of Heating / Oil Bill

Attach Copy of Car Payment

Attach Copy of Car Insurance Bill

Other

Have you, or someone on your behalf, previously submitted an application?

YesNo

Is your recent grave need related to an underlying medical issue?

Yes

If your recent grave need is related to an underlying medical issue, please upload documentation.

Tax Returns

Did you file a tax return last year?

YesNo

Attach a copy of pages 1 & 2 of last year’s Federal (Form 1040) and State (D-400) for yourself and everyone living in the home (click ‘add another response’ to add additional documents)

REQUIRED

The information provided in the application to The EnergyUnited Foundation is true and complete. The Foundation is authorized to verify the information provided. I understand any deliberate falsehoods or efforts to mislead the Foundation will result in denial of the requested assistance.

Note: Any additional documents provided after the application is submitted will not be reviewed.

I understand I will be notified if my grant has been approved or denied. I understand if approved, I will be required to provide past due invoices.

I HAVE READ AND UNDERSTAND THE CRITERIA REQUIRED FOR THIS GRANT

Yes

Contact Information