Page 77

77 | P a g e

APPENDIX V PROOF OF APP ENROLLMENT FOR SER CO-PAYMENT Proof of Affordable Payment Plan enrollment for SER copay Case Name:

Case Number:

Address:

This notice is to verify that the client’s household is being enrolled into an Affordable Payment Plan (APP). Enrollment into an APP can be used to satisfy the household’s shortfall and/or client contribution, per ERM 208 and ERM 301. ____ Enrollment into Consumers Energy’s Consumers Affordable Resource for Energy (CARE) program for the following service(s): ____Natural Gas ____Electricity ____ Enrollment into DTE Energy’s Low-Income Support Plan (LSP) for the following service(s): ____Natural Gas ____Electricity ____ Enrollment into SEMCO’s Monthly Assistance Program (MAP) for Natural Gas services. ____ Enrollment into UPPCO’s Energy Assistance Plan (EASE) for Electrical services. By signing this form, I understand that my SER copayment will not be paid on my behalf at this time and I will be enrolled in my energy provider’s ongoing Affordable Payment Plan to satisfy the copayment requirement for my SER request for energy services.

Print Name

Signature Date I have explained the Affordable Payment Plan(s) with the individual/household member and confirm their eligibility for the program. The household will be enrolled in the APP referenced above in lieu of our agency issuing a direct payment for the client contribution.

MEAP Grantee

Contact Number/Email Address

Print Name

Signature Date

Updated 9/1/20