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ENERGY ASSISTANCE PROGRAMS

Section One: Application Process Intake, Operations & Policy Manual

Program Year 2026 20 “Account Information”) to the State of Oregon, OHCS, its designated subcontractors, and Subgrantees. I understand and agree, should I receive any heating and/or cooling equipment as a result of any of these programs, I agree to hold OHCS, it’s sub grantees and/or contractors harmless. ❖ I hereby authorize and hold harmless my Energy Services Provider(s) for such release of my Account Information for up to two (2) energy assistance program years (10/1 to 9/30) prior to my Application and for three (3) program years (10/1 to 9/30) after my Application is submitted. ❖ I hereby authorize and hold harmless the State of Oregon, OHCS, its designated subcontractors, and Subgrantees in the use (as authorized by OHCS in its sole discretion) of my released Account Information. PART 3: APPLICANT SIGNATURE With my signature I hereby provide the required authorization, approval and acknowledgments to both PART 1 and PART 2 of the ENERGY/WEATHERIZATION ASSISTANCE APPLICATION REQUIRED APPLICANT DISCLOSURES AND APPROVALS.

Applicant Signature Date