Energy Share of Montana Loan/Grant Application

Transcription

1 Energy Share of Montana Loan/Grant Application Energy Share of Montana is a private non-profit corporation designed to assist people who face heating emergencies. Energy Share is a program of last resort. When all other available resources have been depleted, Energy Share may be available. Energy Share funds are donated by private individuals, businesses, and utilities. Funds are distributed by a local Energy Share Board to address heating related emergencies. Decisions related to the approval or the denial of benefits is made by the Board. The funds can be distributed either as a loan, a grant, or a combination of both. During the heating season (October through April), quite often, the Low Income Energy Assistance Program (LIEAP) will address the emergency. An Energy Share benefit is a once-in-a-lifetime benefit of a maximum of $700. Loans are interest free. If the loans/grants are paid back to Energy Share your household would again be eligible to receive further benefits. Situations that are considered heating emergencies include repair or replacement of furnaces, damages that affect the ability to heat the home, and the purchase of heating fuel. Energy Share can help individuals or families and can provide assistance with any heating fuel type. Energy Share can also help prevent the disruption of fuel availability by preventing utility disconnections. Funds are not available for utility security deposits. Application Process 1. Complete the Low Income Energy Assistance Program (LIEAP) application. 2. Enclose verification of income for the past 12 months. 3. Enclose your most recent utility bill. 4. Enclose a copy of the Termination of Services notice. 5. Complete the attached Description of Need form. This form is a very important part of the application process. The Board uses this information to make a decision regarding your request. You need to explain why you need assistance from Energy Share. 6. Complete the Energy Share Questionnaire. 7. Complete the Energy Share Contract. 8. Complete the Authorization to Release Information form. Incomplete Applications Can Not Be Processed

2 DESCRIPTION OF NEED To be considered for Energy Share assistance, the application and all attachments must be completed. Household income will be verified. Incomplete or inaccurate applications cannot be processed. In the space provided below briefly describe the events that put you in need of Energy Share assistance. These events might include losing a job, incurring unusual medical expenses, non-receipt of child support or the like. Please also include the dates of the events. This is a very important part of the application process. Please continue on the back of this sheet if you need more room. Name

3 The purpose of this agreement is to make it affordable for you to pay this loan and be able to keep up on your other responsibilities as well. If something comes up and you are unable to make your scheduled payment please let us know. The minimum amount we can accept is $10.00 per month. Energy Share of Montana Loan Contract I have applied for an Energy Share Loan of $ to be paid directly to my fuel vendor, account number #:. The terms of this loan are as follows: I will repay my no-interest loan at a rate of $ per month. My loan payments will be made to Energy Share and will begin. Signature

4 Energy Share Questionnaire Explain how you have worked with your fuel vendor regarding your bill? Have you attempted to make payment arrangements with your vendor this year? Please indicate your known shut off date: List current employer, or income source and if the employment is FULL or PART time. HH indicates household member. Please estimate the dollar amounts that you pay out on a MONTHLY basis for the following: Car payment: Auto Insurance: Health Insurance: Medical: Prescriptions: Credit Cards: Water: News/Internet: House rent/mortgage: Childcare: Groceries: Phone: Heating bill: Cable: Garbage: Other: How did you hear about Energy Share? My fuel supplier T.V. Radio Friend Case worker Newspaper Other (please specify)

5 Authorization to Release Information I authorize the following utility provider(s): to release or disclose information to the Montana Department of Health and human Services (DPHHS) and to agents or contractors of the DPHHS which is authorized to determine eligibility for the Low Income Energy Assistance Program (LIEAP), Weatherization Program, or Energy Share of Montana Program. Signature Please print the following information: Name: Phone: Cell: Message: Address: _ P.O. Box: City, State, Zip code: HRDC Representative: