Nevada Energy Assistance Form PDF Details

Navigating through the complexities of financial aid for energy costs in Nevada is made manageable with the Energy Assistance Program (EAP). At the heart of this initiative lies the EAP application form, a crucial step for residents looking to alleviate the burden of their annual heating and electric bills. This comprehensive form requires applicants to furnish detailed personal information, including names, dates of birth, and Social Security Numbers for all household members. The process demands a thorough verification of identity, citizenship or legal residency, and proof of residence through documents like lease agreements or mortgage statements. Furthermore, it is imperative for applicants to provide recent utility bills, evidence of all household income for the past thirty days, and, if applicable, an account of how the household's expenses are being met when they exceed income. Considering the strict income thresholds that determine eligibility, this form serves as a gateway to receiving a one-time annual credit aimed at reducing energy expenses. The program emphasizes the importance of submitting a complete application alongside all necessary verifications to avoid delays, and it outlines the procedure for prior beneficiaries regarding reapplication. With two dedicated mailing addresses for submissions, along with fax numbers for Carson City and Las Vegas residents, the form also mentions the potential for eligible households with chronic illnesses to have their countable income adjusted. This intricate process, designed to provide financial relief, underscores the state's commitment to supporting its residents with their energy needs through meticulous documentation and eligibility criteria.

QuestionAnswer
Form NameNevada Energy Assistance Form
Form Length29 pages
Fillable?No
Fillable fields0
Avg. time to fill out7 min 15 sec
Other namesnevada energy dwss online, energy assistance program las vegas, nevada energy assistance las vegas, energy assistance application

Form Preview Example

IMPORTANT NOTICE

How to Apply for the Energy Assistance Program (EAP)

Submit a completed application (to include the name, date of birth and Social Security Numbers for EVERY PERSON who lives in your home) with the following verification:

1.Proof of identity for the head of household (such as a driver’s license, government issued I.D., school I.D., etc.) and;

2.Proof of citizenship or legal status if born outside of the United States and;

3. Proof of where you live:

a.Provide a complete copy of your rental/lease agreement (listing all persons

in your home) and the signature page, or

b.a copy of your mortgage statement and;

7/21

4.Provide a copy of most recent heating/cooling bills and;

5.When the utility bill is not in the applicant’s name, proof of identity for the individual listed on the utility bill is required along with written authorization for

the applicant to apply, that includes their address, phone number and signature

and;

6.Proof of ALL income for EVERY PERSON in the household for at least the last thirty (30) days.

Examples of types of income: Employment, child support, social security, Veterans benefits, retirement, public assistance, utility reimbursements, unemployment insurance, interest income, money from family and/or friends, or organizations, educational scholarships and/or grants, etc.

Note: If the employed individual is working through an employment agency, provide proof of the last 12 months of earned income.

7.If the household expenses exceed the household income, proof of how the household is meeting their needs.

7/21

**FAILURE TO PROVIDE THIS INFORMATION MAY DELAY THE

PROCESSING OF YOUR APPLICATION. **

Prior year recipients may not reapply until approximately 11 months after they

received their last benefit.

Applications are processed in the order in which they are received. Applicants will receive a notice of decision once an eligibility determination has been made.

Please mail or fax your application and verifications to:

Energy Assistance Program

Energy Assistance Program

2527 N. Carson St., #260

3330 E. Flamingo Rd., #55

Carson City, NV 89706

Las Vegas, NV 89121

Fax: (775) 684-0740

Fax: (702) 486-1441

7/21

Division of Welfare and Supportive Services

ENERGY ASSISTANCE APPLICATION

The Energy Assistance Program (EAP) is designed to help eligible Nevada households with their annual heating and electric costs.

INCOME REQUIREMENTS

The total gross monthly income of all household members may not exceed the amounts shown in the chart below.

YOUR HOUSEHOLD’S GROSS MONTHLY INCOME MAY NOT EXCEED:

Persons in

Annual

Monthly

Home

Income

Income

 

 

 

1

$19,320

$1,610

2

$26,130

$2,177.50

3

$32,940

$2,745

4

$39,750

$3,312.50

Persons in

Annual

Monthly

Home

Income

Income

 

 

 

5

$46,560

$3,880

6

$53,370

$4,447.50

7

$60,180

$5,015

8

$66,990

$5,582.50

(For families/households with more than 8 persons, add $6,810 for each additional person).

Households with a chronic or long-term illness, who pay out of pocket medical expenses and whose gross income exceeds the income guidelines, may have their countable income reduced by verified qualifying expenses.

(Page A) 2824 EL (7/21)

BENEFITS

Eligible households receive an annual one-time per year benefit called a “fixed annual credit” customarily paid directly to their energy provider(s). The benefit shows as a

credit on the bill.

MINIMUM PAYMENT The minimum yearly payment for eligible households is $240.

WHEN TO APPLY

If your family is not currently on the program and you meet the income requirements, apply NOW.

If you received a benefit during the past 12 months, a notice will be mailed to you when it is time to reapply. If you submit an application prior to the date you’re eligible to reapply, the application will be denied.

WHAT DO I NEED?

Submit a completed an EAP application with the required documentation. Suggested income verifications are noted on the back of this page. To get answers to other questions, call:

Reno/Carson City

(775) 684-0730

Las Vegas

(702) 486-1404

Toll Free

(800) 992-0900

Visit our website at: http://dwss.nv.gov for more information on the program requirements.

You can find information about the Weatherization Assistance Program at:

http://housing.nv.gov/programs/Weatherization/

(Page A) 2824 EL (7/21)

DOCUMENTATION EXAMPLES OF REQUIRED PROOF OF INCOME

All documentation sent with your application can be either originals or photocopies. If you are unable to photocopy the originals, our office will copy the material and if requested, we will send it back after your case has been processed.

Earned Income: Includes income from employment, self-employment (see below), child care services, house cleaning, and any service for which you are paid. Provide copies of check stubs (if paid in cash, a statement from the person who paid you for a service) for at least the last thirty (30) consecutive days. If paid weekly 4 check stubs; paid bi-weekly or semi-monthly 2 check stubs. If you do not have check stubs, a signed and dated statement of letterhead from your employer stating your gross income for the last thirty

(30)days and how often your get paid, is acceptable. If working through an employment agency or on-call provide proof of the last 12 months of income.

Self-Employment/Non-Profit Business Income: May include profit and loss statements signed by the applicant detailing gross income and expenses (receipts must be provided for deductions) during the last 12 months, a copy of the sales tax statement showing gross net proceeds, financial statements, a loan application listing income and expenses for the last 12 months, or DWSS Form 2011 that includes receipts for allowable deductions. Allowable deductions include: cost of goods sold, supplies and materials, advertising, accounting and legal fees, wages paid to employees, office space rent/mortgage, telephone, utilities, transportation costs necessary to produce income, etc.

(Page B) 2824 EL (7/21)

Unearned Income: Includes income from Social Security Administration, Veterans Administration, pensions, disability, military service, unemployment, child support, alimony, interest, dividends, regular insurance or annuity payments. If you are receiving

Social Security, SSI, Veterans Benefits, pensions, disability income, military income or unemployment: provide copies of the benefit verification form or award letter for the current year showing any cost of living raises. If you are receiving child support/alimony income: provide a copy of divorce decree/separation/settlement agreement or dated letter from the person paying the support (to include name, address and phone number), or a copy of the last check/statement from the child support enforcement agency. If you are receiving interest income/dividends: provide 12 months of bank

account statements, certificates of deposit or other documentation that contains details and is signed by the financial institution, or a broker’s quarterly statement showing earnings.

Cash Contributions and/ or Recurring Gifts: If someone is helping you pay your

expenses or is giving you money: provide a signed statement from each person that includes their name, address, phone number, if the assistance will continue, and the amount provided to you during the last six months. Provide a signed and dated statement by the person providing the money indicating the amount of support, how often it is paid,

when the arrangement began, and whether it is paid directly to a vendor or in cash to you. The statement must include the contributor’s printed name, address(es), and phone

number(s).

(Page B) 2824 EL (7/21)

Student Income: Includes ALL scholarships and grants, e.g., Pell Grant, Federal Supplemental Educational Opportunity Grant (FSEOG), Veterans Administration

educational benefits. Please provide written confirmation of the amount of assistance, and the educational institution’s written confirmation of the cost for the prior two (2) semesters and summer school (if applicable) of the student’s tuition, fees, books and equipment. If

benefits are paid directly to the student, copies of the latest benefit checks or canceled checks or receipts for tuition, fees, books, and equipment are acceptable.

Public Assistance Income: Includes but is not limited to TANF, county general assistance, Clark County Social Services, or American Indian/Alaska Native General Assistance. Provide a written statement from the public agency with the amount paid during the last month, or a copy of the award letter or check.

PLEASE NOTE: 1099 and W-2 forms by themselves are not acceptable as proof

of income.

(Page B) 2824 EL (7/21)

DIVISION OF WELFARE AND SUPPORTIVE SERVICES

ENERGY ASSISTANCE PROGRAM

MAIL OR FAX OUR APPLICATION TO ONE OF THE OFFICES LISTED BELOW OR EMAIL YOUR APPLICATION TO: ENERGYASSISTANCE@DWSS.NV.GOV

LAS VEGAS / NORTH LAS VEGAS 3330 E. Flamingo Rd., #55

Las Vegas, NV 89121

Telephone: (702) 486-1404

Fax: (702) 486-1441

OFFICE FOR ALL OTHER AREAS

2527 N. Carson Street, Suite 260,

Carson City, NV 89706

Telephone: (775) 684-0730

Fax: (775) 684-0740

APPLICATION FOR ASSISTANCE

Please complete every section and answer each question. Sign the application and the Rights and Obligations form. Failure to complete all sections and questions and/or sign the application and Rights and Obligations, OR provide the requested documentation noted on the application, will delay processing your application and may result in your application being denied.

(Page 1 of 21) 2824 EL (7/21)

A. APPLICANT/HOUSEHOLD INFORMATION

Complete the following for every person living in your home, including yourself (attach additional page if necessary). The first name on the application should be the applicant (person listed on the utility bill in the home). Provide proof of identity for the applicant.

 

 

 

 

 

U.S.

 

 

 

 

S

 

 

Citizen or

 

 

 

 

E

 

 

Eligible

 

 

Name

 

X

Date of

A

*Non-

 

Social

(Last, First, Middle)

Relationship

M/

Birth

G

citizen

Disabled

Security

(Jr., Sr., III)

to You

F

(mm/dd/yy)

E

Yes No

Yes No

Number

SELF

Are there additional people in your home?

YES

NO

 

 

If “YES,” list them on a separate sheet of paper.

 

 

 

Home Address (include apartment or unit number)

City

State

Zip

 

 

 

 

Mailing Address (If different from your home address.)

 

 

 

City

 

State

Zip

 

(Page 2 of 21) 2824 EL (7/21)

Home Phone

Day/Message/Cell Phone

E-mail Address

( )

( )

 

 

 

 

*List the names of non-citizen household members authorized as legal residents of the United States.

Provide copies of the front and back of their I-551 (Resident Alien Card) with this application.

B. DWELLING INFORMATION

Renters: Provide a complete signed copy of rent or lease agreement dated within the last 12 months, listing every person living in the home(s). If subsidized, provide signed Housing documents listing every person in the home, rent and utility rebate.

Buyers/Owners: Provide copy of mortgage statement.

1. Dwelling Type:

House

Apartment

Condo/Townhome

Rent Room

Mobile Home

Duplex

Motel/Hotel Travel Trailer

Studio

 

Other: _____________________

 

2. Dwelling Cost:

Rent $____________

Subsidized Rent $____________

 

Buy $____________

Space Rent $__________

Own

(Page 3 of 21) 2824 EL (7/21)

When did you pay off your mortgage? ______________________________________

3.Rent/Buyers only: Landlord, Project/Complex, Mortgage Company Name:

_________________________________________

Address: _________________________________

Telephone No.: (_____) __________________

4.Do you reside in subsidized housing where heating and electric are included in the

rent?

YES

NO

 

 

 

 

IF YES, select all that apply: Section 8

 

Section 42

Other

 

 

C. HELP US BETTER SERVE OTHERS

How did you hear about the Energy Assistance Program? Check one that most applies:

TV

Landlord

Radio

Previous EAP Participant

Print Media

Received Notice in Mail

Social Service Employee

Utility Company (flyer or employee)

Friend

Other: Please identify___________________

 

 

(Page 4 of 21) 2824 EL (7/21)

D. UTILITY INFORMATION

ELECTRIC SERVICE (Attach Copy of

Bill)

Check one that applies:

Receive bill from utility company

Electric service included rent/mortgage Pay separate bill to landlord for electric service

HEATING SERVICE

(Attach Copy of Bill)

Check primary heating source:

Natural Gas

Electric

Propane

Fuel Oil

Kerosene

Wood

Other ________________________

Check one that applies:

Receive bill from utility company

Heating service included rent/mortgage Pay separate bill to landlord for heating service

(Electric Company Name)

(Heating Company Name)

(Electric Account Number)

(Heating Account Number)

(Name On Account)

(Name On Account)

(Page 5 of 21) 2824 EL (7/21)

Is the person

listed on

the account your

Is the person listed on the account your

landlord?

YES

 

 

NO

landlord?

YES

NO

 

 

(If the account holder does not live with you,

(If the account holder does not live with you,

provide their address, telephone number,

provide their

address, telephone

number,

relationship to you, proof of identity for the person

relationship to you proof of identity for the

who is named on the utility bill and a statement

person

 

 

authorizing you to apply for benefits on their

who is named on the utility bill and a statement

behalf.)

 

 

 

 

authorizing you to apply for benefits on their

 

 

 

 

 

behalf.)

 

 

 

 

 

 

 

 

 

 

ARREARAGE ASSISTANCE (Once every five years)

ARREARAGE ASSISTANCE (Once every five years)

Do you have past due charges with your electric utility and want assistance to pay this debt? YES NO

Do you have past due charges with your heating utility and want assistance to pay this debt? YES NO

If your energy provider is NV Energy or Southwest Gas, you need to provide a copy of your current utility bill. For all other energy providers, proof of the last 12 months of usage in dollars and therms, watts and/or gallons for your current address will be required. Proof can be in the form of your last 12 months bills or a print-out from your energy provider.

(Page 6 of 21) 2824 EL (7/21)

E. HOW DO YOU WANT YOUR BENEFIT PAID?

Choose how you want your benefits paid: (Mark ONLY One)

Split my benefit between my electric and heating vendor.

Pay my entire benefit, to my heating vendor

Pay my entire benefit, to my electric vendor

If you choose a split payment your benefit will be split between both of your energy providers not to exceed your annual usage per provider. The benefit may not be an equal 50/50 split.

If you choose a single payment your benefit will be paid to cover your annual usage for that provider, and if there is a remaining balance, it will be paid to your second provider. If you do not choose one of the options above, your benefit will be split between both providers not to exceed the annual usage per provider.

(Page 7 of 21) 2824 EL (7/21)

F. INCOME

1.EARNED INCOME: Does any member of the household, regardless of age, work?

YES

NO If YES, complete the information below:

(Include self-employment, business, child care, housecleaning, odd jobs, temp agencies, and non-profit organization income)

 

 

DATE

 

GROSS

HOW

TIPS

 

 

 

PAY

NAME OF PERSON

 

OF

TYPE OF

OFTEN

PER

 

PER

WORKING

EMPLOYER

HIRE

WORK

CHECK

PAID

MONTH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List all household members, age 18 or older, who are not currently employed:

 

 

 

 

 

 

 

GROSS

 

DO YOU EXPECT

 

 

 

 

 

DATE

 

PAY

 

RE-EMPLOYMENT

 

 

 

FORMER

 

LAST

 

PER

 

PENDING SSI? If YES,

 

NAME OF PERSON

 

EMPLOYER

WORKED

 

CHECK

 

EXPLAIN.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Page 8 of 21) 2824 EL (7/21)

Attach copies of all check stubs or other proof of gross income for at least the last thirty (30) days even if the person is no longer employed. EXCEPTION: 1099s and W-2s by themselves are not acceptable proof of income. Self-employment requires 12 months profit and loss statements.

2.UNEARNED INCOME: Complete the following indicating who, if anyone receives money or benefits from the sources listed below. You must mark YES or NO for each income type and attach proof of all unearned income. 1099s and W-2s by themselves

are not acceptable proof of income.

 

Y

 

 

 

 

 

 

 

 

E

 

N

INCOME TYPE

PERSON

GROSS

FREQUENCY

 

S

 

O

RECEIVING

AMOUNT

 

 

 

 

 

 

 

Alimony

 

 

 

 

 

 

 

 

 

Boarders / Roomers (Attach notarized

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

proof of rental or lease)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Support

 

 

 

 

 

 

 

 

 

Contribution / Gifts / Church or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Charitable Donations

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Educational Assistance / Student Loans

 

 

 

 

 

 

 

 

 

(Attach proof of tuition, books and

 

 

 

 

 

 

 

 

 

supplies for prior TWO semesters)

 

 

 

(Page 9 of 21) 2824 EL (7/21)

Food Assistance (Supplemental Nutrition Assistance Program-(SNAP)

Foster Care

County Assistance / General Assistance

Interest / Dividends / Annuities /

Royalties

Loans

Lump Sum Payments (Settlements / Back Pay, etc.)

Military Income / Allotment

Mining Claims

Panhandling

Pensions / Retirement

Property Rentals / Sale

Railroad Retirement

Room Rental (Attach notarized proof of rental or lease)

Social Security Benefits (RSDI)

Strike Benefits

Subsidized Housing

Supplemental Security Income (SSI)

Supported Living Arrangement (SLA)

TANF Assistance

(Page 10 of 21) 2824 EL (7/21)

Tribal Assistance / Indian General

Assistance (IGA)

Trust Income (Provide proof if it is not accessible)

Unemployment Insurance

Utility Allowance / Rebate Check

Veterans Benefits

Winnings

Worker’s Compensation or Temporary

Disability

Other

(Page 11 of 21) 2824 EL (7/21)

MEETING EXPENSES

1.If the household expenses (e.g. rent, utilities, food, etc.) are more than your household’s income, explain how you are able to meet these expenses.

2.If someone is helping you meet your expenses or is giving you money, you must provide a signed statement from each person that includes their name, address, telephone number and the amount of help they provided to you during each of the last six months. Below, fill out the information of the person(s) who provided you a

statement:

Name of Person Assisting

Address

Phone Number

Amount

How Often

 

 

 

 

 

 

 

 

 

 

Do you expect any changes in the household’s income or benefits?

YES

 

NO

 

If YES, what? __________________________________________

 

 

 

When? ________________________________________________

 

 

 

Changes in income prior to certification will be used to determine eligibility.

(Page 12 of 21) 2824 EL (7/21)

G. RESPONSIBILITY

Information provided in this application is subject to verification and investigation by federal, state, and local officials. If you make a false or misleading statement, misrepresent, conceal or withhold facts, or fail to report changes to establish or maintain eligibility for energy assistance, your benefits may be denied, terminated or reduced. You are responsible for repayment of all monies, services and benefits for which you were not entitled. Additionally, you may also be barred from program participation, criminally prosecuted and/or otherwise penalized according to state and federal law

Have you ever been determined to have committed an Intentional Program Violation (IPV)?

YES NO

If YES, in what State?____________________________

H. AUTHORIZATION

By signing this application, I am authorizing the Department of Health and Human Services to make any investigation concerning me or any other member of my household which is necessary to determine eligibility for benefits received or to be received under programs administered by the Division of Welfare and Supportive Services. I hereby authorize and consent to the release of any and all information concerning me and/or my household members

(Page 13 of 21) 2824 EL (7/21)

to the Division of Welfare and Supportive Services by the holder of the information regardless of the manner or form held, including by, without limitation, wage information, information made confidential by law or otherwise privileged under NRS 422A.342 or any other provision of law or otherwise. I authorize the Energy Assistance Program to release information about my household, to include energy usage information, to the State of Nevada Housing Division, Weatherization Assistance Program, for potential eligibility in weatherizing my residence. I hereby release the holder of such information from liability, if any, resulting from the disclosure of the required information. I ACKNOWLEDGE THAT A REPRODUCED

COPY OF THIS AUTHORIZATION LEGALLY CONSTITUTES AN ORIGINAL COPY. Initials _____________

If I am 60 years of age or older, I hereby consent to the disclosure of my identity and waive my rights as an older person to have my identity kept confidential. I hereby release the holder of information from liability, if any, resulting from the disclosure of the required information.

Initials _____________

I consent that the Division of Welfare and Supportive Services or its representatives may survey my energy usage, advise providers or assistance grants, and status at the time of certification. I consent that the Division of Welfare and Supportive Services use Social Security Numbers (SSNs) provided on this application to verify factors of energy assistance program eligibility, which may include automated data exchanges with the Social Security Administration.

I agree to notify the Energy Assistance Program of any changes in my household

(Page 14 of 21) 2824 EL (7/21)

circumstances that may affect my benefits. I understand failure to report changes may cause an overpayment, which I would be responsible to pay back and could even be prosecuted by a court of law. I swear I have honestly reported the citizenship of myself and anyone I am applying for.

I certify under penalty of perjury, my answers are true, correct and complete to the best of my knowledge and ability.

Print Name of Applicant:

Signature of Applicant:

 

 

Date:

 

Print Name of Other Adult

 

 

 

Member(s) in Household:

 

 

 

Signature of Other Adult

 

 

 

Member(s) in Household:

 

Date:

Print Name of Other Adult

 

 

 

Member(s) in Household:

 

 

 

Signature of Other Adult

 

 

 

Member(s) in Household:

 

Date:

 

(Page 15 of 21) 2824 EL (7/21)

WITNESS: (Use if applicant cannot read or write or is blind.) I have assisted with the completion of this application for Energy Assistance. The information in this application has been read to the applicant and I have witnessed the above signature.

______________________________________

Print Name of Witness

 

______________________________________

________________________

Signature of Witness

Date

(Page 16 of 21) 2824 EL (7/21)

Division of Welfare and Supportive Services

ENERGY ASSISTANCE PROGRAM

NOTICE OF RIGHTS AND OBLIGATIONS

**** PLEASE READ AND SIGN BELOW ****

A.You have the following RIGHTS:

1.No person will be discriminated against for any reason, e.g. race, age, color, religion, sex, disability, handicap (including AIDS and AIDS related conditions), political belief or national origin, in any program administered by the Division of Welfare and Supportive Services. When the Energy Assistance Program (EAP) pays another agency, institution or person to provide EAP services to a household, the provider is not permitted to discriminate for any reason. Violations of discrimination shall be promptly reported to the Energy Assistance Program office, the Division of Welfare and Supportive Services Administrator, 1470 College Parkway, Carson City, Nevada 89706-7924, (775) 684-0500, the U.S. Office for Civil Rights (OCR), Department of Health and Human Services, 50 United Nations Plaza, San Francisco, California 94102, (415) 437-8310, TDD (415) 437-8311, or by calling toll free 1-800-368-1019.

2.You have the right to a conference if you believe you have been unfairly treated or a mistake has been made concerning your eligibility for assistance. To request a conference, write or call the Energy Assistance Program.

3.You have the right to a hearing if you are not satisfied with the agency’s action affecting your assistance if you request the hearing, in writing, within ninety (90)

(Page 17 of 21) 2824 EL (7/21)

days of the agency’s action/decision, unless the sole issue for the agency’s action/decision is one of state or federal law requiring automatic benefit adjustment. You have the right to a hearing if your application is denied, acted upon erroneously, or not acted upon with reasonable promptness, or if your benefits have been reduced.

4.You have the right to a mailed notice of decision telling you if you are eligible for program benefits and in what amount, to whom payments will be made, and the approximate payment date(s); or a notice informing you that you are not eligible for program benefits and why.

5.Program staff are required to:

Inform applicants of the eligibility requirements for the program;

Counsel on required documents; and/or

Provide assistance to the applicant, when needed.

B. You have the following OBLIGATIONS:

1.Notify the Energy Assistance Program within ten (10) calendar days of any of the following. Failure to do so may delay processing your application, or result in denial of benefits or a reduction in benefits.

Any change in your household income or household size (number of people residing in the household);

If you change utility companies; or

If you move anytime after submitting your application.

(Page 18 of 21) 2824 EL (7/21)

2.Respond to any requests for additional information needed to process your application within ten (10) calendar days. It is your responsibility to ensure the requested materials are mailed or faxed early enough to meet the deadline provided to you. The Energy Assistance Program is not responsible for lost or misdirected mail, or faxes. (Be sure your name and SSN or UPI are on all documents/correspondence.)

3.Cooperate with the Energy Assistance Program in its efforts to secure all information necessary to determine eligibility or benefits

B.SPECIAL NOTE:

1.If you are applying for the Energy Assistance Program, you may receive help with your heating and/or electric bills. BUT REMEMBER, YOU MUST KEEP PAYING YOUR BILLS WHEN THEY ARE DUE. If you do not pay them, the company can charge more money for paying late. The utility company can even turn off your service and you may be required to pay a deposit before they will turn your service on again. If you cannot pay your bill, contact the utility company and try to make payment arrangements.

(Page 19 of 21) 2824 EL (7/21)

2.Persons found guilty of intentionally violating program rules will be ineligible for program participation for one (1) year for the first violation, two (2) years for the second violation, and permanently barred from the program for the third violation.

My signature below indicates I understand the Rights and Obligations as an applicant for the Energy Assistance Program.

Print Name of Applicant:

 

 

 

Signature of Applicant:

 

 

Date:

 

Print Name of 2nd Adult:

 

 

 

Signature of 2nd Adult:

 

 

Date:

 

(Page 20 of 21) 2824 EL (7/21)

IF YOU ARE NOT REGISTERED TO VOTE WHERE YOU LIVE NOW,

WOULD YOU LIKE TO REGISTER TO VOTE HERE TODAY?

(Please check one)

YES

NO

If you do not check either box, you will be considered to have decided not to register to vote at this time.

The NATIONAL VOTER REGISTRATION ACT provides you with the opportunity to register to vote at this location. If you would like help in filling out a voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.

IMPORTANT NOTICE: Applying to register or declining to register to vote WILL NOT AFFECT the amount of assistance you will be provided by this agency.

Signature

Date

CONFIDENTIALITY: Whether you decide to register to vote or not, your decision will remain confidential.

IF YOU BELIEVE SOMEONE HAS INTERFERED with your right to register or to decline to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Office of the Secretary of State, Capitol Complex, Carson City, Nevada 89710.

(Page 21 of 21) 2824 EL (7/21)

How to Edit Nevada Energy Assistance Form Online for Free

Working with PDF files online is always surprisingly easy using our PDF editor. Anyone can fill out dwss nv gov energy assistance here within minutes. To have our tool on the forefront of efficiency, we aim to put into operation user-driven features and improvements on a regular basis. We are routinely happy to receive suggestions - join us in revampimg how you work with PDF documents. To get the ball rolling, go through these basic steps:

Step 1: Click the "Get Form" button in the top area of this page to get into our editor.

Step 2: The editor lets you change PDF forms in a range of ways. Modify it with personalized text, correct what is originally in the file, and place in a signature - all possible in no time!

It will be simple to complete the form using out helpful tutorial! Here is what you should do:

1. First, while filling out the dwss nv gov energy assistance, start in the part containing following fields:

Find out how to fill in nevada energy assistance las vegas part 1

2. Right after finishing the previous part, go to the subsequent step and complete all required details in these blanks - Home Phone, DayMessageCell Phone, Email Address, List the names of noncitizen, the United States, Provide copies of the front and, B DWELLING INFORMATION, and Renters Provide a complete signed.

Email Address, B DWELLING INFORMATION, and Provide copies of the front and of nevada energy assistance las vegas

3. Through this part, have a look at Renters Provide a complete signed, Dwelling Type, House, Apartment, CondoTownhome, Rent Room, Mobile Home, Duplex, MotelHotel, Travel Trailer, Studio, Dwelling Cost, Rent, Subsidized Rent, and Other. All these need to be filled out with greatest accuracy.

Writing segment 3 of nevada energy assistance las vegas

Be really careful while filling out Rent and Rent Room, since this is where most people make errors.

4. This subsection arrives with the next few empty form fields to type in your particulars in: When did you pay off your mortgage, RentBuyers only Landlord, Address, Telephone No, Do you reside in subsidized, rent, YES, IF YES select all that apply, Section, Section, Other, C HELP US BETTER SERVE OTHERS, How did you hear about the Energy, TV Radio Print Media Social, and Landlord Previous EAP Participant.

Do you reside in subsidized, Other, and C HELP US BETTER SERVE OTHERS in nevada energy assistance las vegas

5. To wrap up your form, this last subsection features some extra blank fields. Entering TV Radio Print Media Social, Landlord Previous EAP Participant, and Page of EL will finalize the process and you'll definitely be done quickly!

Filling out segment 5 of nevada energy assistance las vegas

Step 3: Proofread all the details you've inserted in the form fields and then click the "Done" button. Join FormsPal right now and immediately use dwss nv gov energy assistance, prepared for downloading. All modifications you make are preserved , so that you can customize the file at a later time if needed. FormsPal is committed to the confidentiality of our users; we make sure that all personal data handled by our editor remains protected.