Page 27

ENERGY ASSISTANCE PROGRAMS

Section One: Application Process Intake, Operations & Policy Manual Program Year 2026 27 ➢ Utility/vendor account number(s) (if this is a cash account, how is the account verified by the utility/vendor?) ➢ Verification of name and address on account(s) ➢ Account balance ➢ Signature of agency representative completing form (clients may not fill out the Utility Verification Form for themselves, it must be done by agency staff) 5. Justification for any benefit other than a regular payment as described in Section Three. This includes: ➢ Direct Payment ➢ Crisis/Combo – reason for crisis and amount of payment ➢ Heating or Cooling Equipment Repair/Replacement – (See Section Three) ➢ Roomer/Boarder Payment ➢ Health & Safety ➢ Fuel Payment 6. Copy of all correspondence/documentation such as: ➢ Notice of Action (NOA) ➢ A NOA is required when an application is pended or when a benefit amount changes. A NOA may be required by the local agency for other changes or modifications. ➢ Declaration of Household Income Form (DHI) and/or other local agency form(s) ➢ Self-Employment Form ➢ General Release of Information Form ➢ Subsidy Verification– verification is only required if the household is not receiving a utility allowance.

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Page 27

Official source

ENERGY ASSISTANCE PROGRAMS

Section One: Application Process Intake, Operations & Policy Manual Program Year 2026 27 ➢ Utility/vendor account number(s) (if this is a cash account, how is the account verified by the utility/vendor?) ➢ Verification of name and address on account(s) ➢ Account balance ➢ Signature of agency representative completing form (clients may not fill out the Utility Verification Form for themselves, it must be done by agency staff) 5. Justification for any benefit other than a regular payment as described in Section Three. This includes: ➢ Direct Payment ➢ Crisis/Combo – reason for crisis and amount of payment ➢ Heating or Cooling Equipment Repair/Replacement – (See Section Three) ➢ Roomer/Boarder Payment ➢ Health & Safety ➢ Fuel Payment 6. Copy of all correspondence/documentation such as: ➢ Notice of Action (NOA) ➢ A NOA is required when an application is pended or when a benefit amount changes. A NOA may be required by the local agency for other changes or modifications. ➢ Declaration of Household Income Form (DHI) and/or other local agency form(s) ➢ Self-Employment Form ➢ General Release of Information Form ➢ Subsidy Verification– verification is only required if the household is not receiving a utility allowance.