Lsp Program Dte – Fill Out and Use

LOW INCOME

SELF-SUFFICIENCY PLAN (LSP)

AN AFFORDABLE MONTHLY PAYMENT PLAN

•Enroll in DTE Energy’s LSP plan.

•Once enrolled you will pay a ixed monthly amount for your utilities, and the program will pay the difference between the plan amount and your monthly bill.

•Other program beneits include access to dedicated Customer Advocates, self-suficiency supports, protection from shutoff, no future late payment charges and the reduction of your outstanding balance.

•Any three missed payments during the year will result in plan termination.

•To qualify, income must be equal to or less than 150 percent of the Federal Poverty Level (FPL) Guidelines (see chart below).

~You must not have used more than $2,150 in natural gas in the prior 12 months, $1,600 in electricity or $3,750 in both natural gas and electricity.

~Applicant must have an active service and no unauthorized usage.

~Arrears must not exceed $4,000.

•If you have access to the internet, web application submissions are preferred for faster eligibility determination; apply online at https://lspapp.liveunitedsem.org

*For each additional household member over 8 add $522.50

PLEASE ALLOW 10 DAYS FOR APPLICATION PROCESSING

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Attach extra pages if you need to include additional members. List everyone who lives in your home, including adults and children temporarily absent due to illness or employment. People are considered members of your household if they sleep and keep their belongings in your home. Be sure to include the date of birth and citizenship status for each member.

Household Address (Service Address)

Address (Numbers & Street Name, Apt., etc.)		City
State	County	Zip Code

Mailing Address, if different than above

Additional Information Needed

Is anyone in the household: pregnant? 18 years old and in high school?						o Pregnant o 18 yrs/high school o No
Home Heating Credit (HHC): Have you applied for or received the HHC (Energy Draft)						o Yes, month received_____________ o No
in the last 6 months?
Have you or do you currently receive benefits from Department of Health and						o Yes	o No
Human Services (DHHS)?
Have you received energy assistance from another agency or through a provider-						o Yes, who was the provider(s):___________
sponsored program since October 1?						o No
How do you heat your home?	o Natural Gas	o Propane			o Wood		o No heat Obligation
(Select One)	o Fuel Oil	o Electric Heat*			o Coal		o Other:___________
*Electric heat sources include solar panel, boilers, radiators, or baseboard heating, but DO NOT include space heaters
Emergency Need: Check the service(s) that you are			o	Household Heating $_________
				If this is a prepaid account, amount in the account $_______
requesting and the amount needed to resolve the				*If deliverable fuel, percentage remaining in tank ________%
emergency for 30 days.			o	Electricity (non-heating) $_____________________
				If this is a prepaid account, amount in account $ _________

*Payment for deliverable fuel will not be made if, at the time of delivery, it is confirmed that you have more than 25 percent of fuel remaining in your tank.

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	Electric (non-heat) Provider Information
	LOW INCOME
	Name and address of company/energy provider				Account number
	SELF-SUFFICIENCY PLAN (LSP)
	Service Address				Name on account
	Has your electricity been turned off?				o Yes, Date service was turned off: __________				o No
	Have you received a past due or shut off notice for your electricity?				o Yes, when is service scheduled to be turned off: __________
					o No
	Household Heating Provider Information
	Name and address of company/energy provider				Account number
	Service Address				Name on account
	Has your heat been turned off or have you run out of your				o Yes, Date heat was turned off or fuel ran out: __________
					o No
	only heating fuel source?
	Have you received a past due or shut off notice for your heat or are				o Yes, number of days until fuel runs out or date service is scheduled
	you at risk of running out of your household heating fuel?				to be shut off: __________
					o No
	Household Income
	Does your household have any income?				o Yes, Total monthly Income $___________			o No
	Please check all sources of income that your household expects to receive in the next 30 days
	o Social Security		o Disability Benefits			o Employment/earned income
	o Supplemental Security Income (SSI)		o Self-employment Income			o Worker’s Compensation
	o Pension/retirement benefits		o Unemployment			o Money from family/friends
	o Veteran’s Benefits/Military		o Child Support			o Other (ex: lottery winnings) please
	Allotments					list:________________________

oTribal payments (Energy Assistance/LIHEAP, tribal GA, casino/gambling profit sharing, land claims, etc.)

oRental income or a land contract, mortgage or other payment payable to a household member

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Income Expenses

LOW INCOME

Check all expenses that apply to your household and the following information. Attach proof for each.

SELF-SUFFICIENCY PLAN (LSP)

How often paid?

Covers what time period?

o Health insurance premium

Amount

$

o Court ordered child support

Amount

How often paid?

Covers what

time period?

$

o Actual child care costs paid by an employed household

Amount

member, not DHHS

$

o Unusual employment related

Amount

Explain Expense

expenses

$

Signature Requirement

Please sign below after reading the following information, otherwise this application will be considered incomplete

•By requesting assistance through MEAP, you may be referred to, or required to, participate in additional services such as budgeting assistance, energy audits, or other programs that will help your household pay energy bills and understand energy consumption.

•I understand I have eight calendar days to provide all verifications requested and failure to provide the above information may result in denial of my application. I understand giving false information can result in referral to the prosecutor for fraud. I understand that my application may be one of those chose for a complete investigation. An agency or department representative may call at my home and may contact other people in order to verify my eligibility for assistance.

•I authorize my energy company to release by phone, fax, email or their computer website all available information about my account.

•I authorize the assisting agency or provider to release my name and address to the local weatherization operator as part of the Weatherization Referral system. I authorize the department to release case and payment information to the Department of Health and Human Services, its affiliates and/or contracted agencies, for the purpose of research, study and evaluation of the Low Income Home Energy Assistance Program (LIHEAP) and the Michigan Energy Assistance Program (MEAP).

•I authorize United Way for Southeastern Michigan to share the information contained in this application with agencies that can provide additional energy assistance and services, and I grant authorization to those agencies to share information back to United Way for Southeastern Michigan.

•UNDER PENALTIES OF PERJURY, I SWEAR OR AFFIRM THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO ME. IF I AM A THIRD PARTY APPLYING ON BEHALF OF ANOTHER PERSON, I SWEAR THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO THE APPLICANT. TO THE BEST OF MY KNOWLEDGE, THE FACTS ARE TRUE AND COMPLETE.

Request for Review

If you believe any action of the agency is incorrect, or if the decision to approve or deny your application is not made within 10 (ten) days of the application date, you have the right to request a hearing. A request for a hearing must be in writing, signed by you or your authorized representative, and received by the agency making the eligibility determination within 90 days following the date of this form.

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In addition to utility assistance, United Way can also provide LSP customers with additional services

and resources to help meet their basic needs. Your answers to the questions below WILL help us direct you to additional services that may beneit you and your household. Your answers to these questions WILL NOT inluence your eligibility for utility payment assistance in any way.

SUPPLEMENTAL APPLICATION QUESTIONS

1.United Way can offer LSP customers the following services and resources. Please select all options which you would be willing and able to participate in.

qI would like to participate in a Facebook group with other LSP customers, where I can share and receive information about resources in my community

qI am interested in receiving one-on-one inancial coaching and community referrals from a LSP Care Coordinator over the phone

qI would like to be referred to my local Community Action Agency for in-person services and resources

qI am interested in receiving services through the Family Independence Initiative, by meeting with peers in-person and online on a regular basis to work towards my goals

qI will call United Way’s 2-1-1 hotline if I need anything

2.Email address: __________________________________________________________________

I authorize United Way for Southeastern Michigan (UWSEM) to send text messages to my cell phone to convey information regarding additional services.

qYes

qNo

3.If your household has no income, are you able to make the monthly ixed payment required for enrollment at LSP?

qYes. Please explain. ________________________________________________________________________

qNo. Please refer me to other programs.

qNot applicable. My household has income.

4.What language do you most often speak?

qEnglish

qSpanish

qArabic

qOther ____________

HOUSEHOLD INCOME

5.Does your household’s monthly income cover your basic needs other than electric and gas utilities? (including SSI, disability, and other forms of government or family assistance)

qAlmost Always True

qSometimes True

qRarely True

qDon’t Know

6.My household has the ability to set aside a portion of my income on a monthly basis?)

qAlmost Always True

qSometimes True

qRarely True

qDon’t Know

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HOUSING STATUS

7.Does your household need assistance to be able to stay in your current housing OR to ind and maintain other, safer, or more stable housing?

q Yes q No

q Don’t Know

8.Are you able to stay in your current housing for the near future? q Yes

q No

q Don’t Know

FOOD AVAILABILITY

9.Is your household currently able meet its basic food needs? That is, are the members of your household able to purchase and prepare adequate amounts of healthy food?

q Almost Always True q Sometimes True q Rarely True

q Don’t Know

10.If you have children in your household, do they receive free or reduced price lunch at school? q Yes

q No

q Don’t Know

q No Children in the Household

11.Can any members in your household easily walk, drive, or take the bus to your local grocery store/food pantry? q Yes

q No

TRANSPORTATION

12.Is your household able to meet your basic travel needs? Basic travel needs include the ability to get to work, school, appointments, religious services, and grocery shopping.

q Almost Always True q Sometimes True q Rarely True

q Don’t Know

13.If you, or someone in your household, uses a car, is it insured? q Yes

q No

EMPLOYMENT

14.Which of the following categories best describes your employment status? q Employed, working 40 or more hours per week

q Employed, working 1-39 hours per week q Not employed, looking for work

q Not employed, not looking for work q Retired

q Disabled, not able to work

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15.If you are currently employed, does your job provide you with beneits?

qYes

qNo

qDon’t Know

CHILD CARE

16.Does your household have child care available when needed? q Almost Always True

q Sometimes True q Rarely True

q No Children in the household q Don’t know

17.Is your household able to cover the costs for the child care available? q Almost Always true

q Sometimes True q Rarely True

q No Children in the household q Don’t know

HEALTHCARE COVERAGE

18.Are members in your household able to get adequate medical care when needed? q Almost Always True

q Sometimes True q Rarely True

q Don’t Know

19.Are members in your household covered by an affordable health insurance plan(s)? q Almost Always True

q Sometimes True q Rarely True

q Don’t Know

EDUCATION

20.Does anyone in your household need to obtain a GED (a general equivalency diploma)? q Yes

q No

q Don’t Know

21.Is anyone in your household interested in a job training or certiication program? q Yes

q No

q Don’t Know

22.Is anyone in your household interested in receiving English as Second Language (ESL) programming? q Yes

q No

q Don’t Know

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