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Fuel and Electric Assistance Program ApplicaƟon 2026-2027

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CHECKLIST: In addition to the completed, signed application, please submit copies of the following: ☐ Proof of SSN for all household members* (e.g. copy of SS card, tax form) or legal non-citizen status

*If proof of SSN was provided last season (2025-26), it may not be needed again this year ☐ A recent, complete electric bill (for Electric Assistance) ☐ A recent account statement, fuel delivery slip or utility bill for primary heat source (for Fuel Assistance) ☐ Households with heat included in rent must submit a completed Landlord/Housing Verification form ☐ Proof of GROSS income for all household members in the month prior to the date you sign application:  If employed, provide paystubs for prior 5 weeks or have your employer(s) complete an Employer Verification Form  If self-employed, provide most recent tax return – include complete signed 1040 with all schedules & attachments  If receiving Social Security, SSI or SSDI, provide Social Security award letter for current year  If receiving DHHS Assistance, provide complete copy of most recent decision letter  If receiving pension or VA cash benefits, provide proof of total gross amount received in prior month  For any retirement withdrawals in past 365 days, provide proof of total gross amount withdrawn in past year  For any annuities, interest, or dividends, provide most recent tax return or 1099  If receiving unemployment, disability, or worker’s comp, provide proof of gross amount for past month  If receiving alimony, provide proof of gross amount for past month  If paying child support, provide proof of gross amount paid in past month  If household has no income, please contact us to request and complete a No or Low Income form  Additional documentation may be requested by program staff o _______________________________________________________________________________ Release and Conditions: By signing this application, I acknowledge that I have read and understand all the terms and conditions outlined in the program requirements and agree to comply with all rules and regulations set forth by the program administrators. I confirm that all members of the household are listed along with all sources of income. I authorize the Fuel, Electric, and Weatherization Assistance Programs to contact any necessary third party to collect and verify household income and energy usage. I authorize the verification of all information provided and consent to the collection, storage, and processing of my personal data for the purpose of program evaluation and reporting.

I hereby attest under penalty of perjury that all information provided in this application for the program is true, accurate, and complete to the best of my knowledge. I understand that if I knowingly give inaccurate or incomplete information pertaining to my eligibility for the program(s), I am breaking the law and can be prosecuted; conviction may result in imprisonment and/or fine. Furthermore, I may be subject to administrative penalties which may include denial of eligibility and/or repayment of the assistance I received. I understand that this application is only a request for assistance and assistance is based on the availability of funds. No assistance can be provided until the application is completed and approved. I understand that the Electric Assistance Program benefit is provided to assist our household in making full and timely payments on my electric bill. NH’s Fuel, Electric, and Weatherization Assistance Programs prohibit discrimination based on race, color, creed, religion, sex, age, national origin, marital status, sexual orientation, familial status and physical or mental disability.

Applicant Signature _____________________________________________ Date ________________

For Office Staff Use Only

Current EAP Case #: EAP Recert Due Date: Usage: Current Tier: New Recert Return If recert not due, did client request appointment? Y N Notes