Nevada Energy Assistance Form – Fill Out and Use This PDF

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;

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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.

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**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:

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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:

(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.

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 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:

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/

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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.

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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).

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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.

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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

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.

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*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.

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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

C. HELP US BETTER SERVE OTHERS

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

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D. UTILITY INFORMATION

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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.

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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.

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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.

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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

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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

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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:

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

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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

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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:

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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.

______________________________________

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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)

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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.

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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.

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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.

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

WOULD YOU LIKE TO REGISTER TO VOTE HERE TODAY?

(Please check one)

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.

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.

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