STATE OF WISCONSIN HOME ENERGY PLUS PROGRAM

DEPARTMENT OF ADMINISTRATION
DIVISION OF ENERGY, HOUSING AND https://energyandhousing.wi.gov/
COMMUNITY RESOURCES
(R06/2024)

Home Energy Plus Application

To apply for Energy Assistance online go to https://energybenefit.wi.gov
This form is authorized under Wisconsin State Statute 16.27(2)(a). All information on the application is required in order to determine eligibility for
benefits under the Home Energy Plus Programs.
1. First Name: Middle Initial: Last Name: (As shown on Social Security card)

2. Alias First Name (if applicable): Alias Last Name (if applicable):

3. Primary Phone Number: ( ) Home Work Cellular Contact

Secondary Phone Number: ( ) Home Work Cellular Contact

4. Email address: Preferred Communication Method: Phone Email Mail Text Message
5. Chek the housing type you live in:
Single family house Mobile home Motel/Camper/RV Other____________
2 to 4-unit building (including condos) – Number of units/apartments in your building:
Apartment or multi-unit building (including condos) – Number of units/apartments in your building:
6. Mailing Address (if different than residence address):
Address City State Zip
7. Residence Address (must complete): County or Tribe in which you live:
Address City State Zip
Do you Own or Rent your home? Own Rent (Select “Own” if you own a mobile home and pay lot rent)
If renting, provide Management Company/Business Name (as applicable): Point of Contact or Landlord Name:

Landlord Email Address: Landlord Phone Number:

( )
Landlord Address: City: State: Zip:

8. Provide the number of rooms in your residence:

Living Room Dining Room Kitchen Family Room Number of Bedrooms Den/Office

9. Select the response that best describes your living arrangement as of the date of this application:
Live in a group home, half-way house, Community Based Residential Facility (CBRF) or foster home
Live in a nursing home Live in a government institution or prison or jail
Are currently in a homeless situation moving to a permanent residence None of the above
10. Do you receive rental assistance (Section 8 or other government assisted housing)? Yes No
11. Is there a guardian or designated representative? Yes No If yes, complete representative information:
Authorization of Representative Legal Guardian Power of Attorney (POA) Protective Payee

Guardian/Representative Name: Guardian Phone Number: ( )

City: State: Zip:
Address:
OR: List someone you are authorizing to discuss your application with who is not listed as a guardian or designated
representative: Relationship:

12. Are you (the applicant) a student under the age of 25 and enrolled at least half-time in an institution of higher learning?
Yes No If yes, check any of the following conditions that meet your situation:
Currently working twenty or more hours per week making at least minimum wage
Financially responsible for a child under age 18 who is living with you
Physically or mentally disabled (verification needed from government program)
Receiving Unemployment Compensation (UC) benefits resulting from TAA / NAFTA (must be a full-time student)
Receiving TANF or W-2 Benefits Spouse lives with you who is not a student None of the above apply

13. Is anyone living with you under the age of 18 and related to any adult household member? Yes No
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 14. How many people live in your home (including you, the applicant listed on page 1): _________________________________
Identify the preferred household language: _____________________________

HOUSEHOLD MEMBERS:

Military Service

Child in Shared
List all who are living in this residence today.

Foodshare

Placement
•

US Citizen
The agency will contact you for Social

Ethnicity

Disabled
Security Numbers (SSNs) if needed.

Gender

Race
First MI Last (Legal Name) Birthdate
See See
Example: John M Doe mm/dd/yyyy Y/N Y/N Y/N Y/N Y/N
below below
1 (Name from Page 1)

Please attach a separate sheet if necessary for additional household members.

Ethnicity (Enter Code): 1 = Hispanic/Latinx 2 = Non-Hispanic/Non-Latinx 3 = Unknown 4 = Decline to answer

Race (Enter Code): A = Asian B = Black or African American H = Hispanic/Latinix I = American Indian or Alaska Native
M = Multi Race (2 or more) O = Other P = Native Hawaiian or Other Pacific Islander W = White U = Unknown D = Decline to answer

HOUSEHOLD INCOME: Does your household have zero income? Yes No

Check All Boxes that apply below:

 (A) Alimony Received  (GF) Gift/donations  (SSDI) Social Security Disability Insurance
 (CS RECD) Child Support Received  (GV) Government Relief or Disaster  (SSI) Supplemental Security Income
 (CS Paid) Child Support Paid  (LC) Land Contract Payment  (T) TANF/W2
 (CTS) SSI Caretaker Supplement  (O) Other  (TR) Tribal per Capita
 (DL) Disability Long-term  (P) Pensions, Annuities, and IRAs  (UC) Unemployment Compensation
 (DS) Disability Short-term  (R) Rental Income  (V) Veterans Benefits
 (D) Dividends/Interest  (SE) Self-Generated Income  (W) Wages & Tips
 (G) Gambling/Lottery/Bingo  (SP) Spousal Impoverishment  (WK) Workers Compensation
 (GR) General Relief  (SS) Social Security

Household Member’s Name Income

Income Source
Type
Example:
ABC Corporation
John Doe W

Attach a separate sheet if necessary for additional income.

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ENERGY FUELS:
Primary Heating – Only select one Electricity
Fuel Type: Natural Gas Electric Check here if you do not have electric service
Propane Fuel Oil Wood in your home from a utility, municipality, or
Both Primary Heating and
Electricity columns must be Other (Describe: ) cooperative.
completed if you do not have Check here if your furnace/heating unit is not Indicate alternate electric source:
electric heat. working: Solar Generator Off Grid Other

How is the bill paid? I have an account and pay my bill directly to I have an account and pay my bill directly to
the provider the provider
Check one for Primary Heat is included in my rent Electric is included in my rent
Heating and one for
Electricity. Separate payment to my landlord, mobile Separate payment to my landlord, mobile
home park owner, or other person home park owner, or other person
I do not pay: heat included in the monthly rent I do not pay: electric included in the monthly
when residing in government assisted housing or rent when residing in government assisted
have an in-kind arrangement housing or have an in-kind arrangement
Business or recreational
Yes No Yes No
use on the meter
*Company Name: *Company Name:
Account Information
Account Number: Account Number:
*Electric company for your
home must be listed even if Energy Account Holder:
you don’t have a direct Energy Account Holder:
Household member
account with a vendor. Household member
A deceased spouse
A deceased spouse
A Protective Payee
A Protective Payee
Other – identify relationship of account
Other – identify relationship of account holder:
holder:
Name on Account: Name on Account:

If your primary heat source is natural gas or electric, have you received a past due or disconnect notice within the last 90 days?

Yes No Not applicable Is this account currently disconnected? Yes No

If your primary heat source is propane or fuel oil, does your tank currently have equal to or less than 20% of fuel remaining?

Yes No Not applicable Are you currently out of fuel? Yes No

Hot water: Identify fuel type that heats the water in your home: Electric Fuel Oil Natural Gas Propane (LP)

Wood and Other None

Additional heating source: Identify additional heating sources used in your home such as fireplace, wood burner, space heaters, or
other alternative heating source. Electric Wood or Other___________________________ None

Air Conditioning Type (select only one): None Central A/C Wall/Window Unit A/C

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Certification Page
Person ID: Application #:
Read each item on this page before signing the application.
If you do not understand any item, ask the worker for assistance.

1. I understand I am responsible for providing all required information within 30 days of the date of the application or the
application is void and will be denied. I may reapply but a new application may be required.

2. I understand I am responsible for reporting the names of all persons living at my address and the Social Security number and
income of all persons in my household. Collection of Social Security numbers is not prohibited by federal law and is a required
data element for tracking applicant benefits granted by this Program. Failure to provide this information will result in delayed
processing of my application and the inability to determine benefit amounts.

3. I understand I am responsible for using the payments I receive to pay for the heating/electric costs for the residence listed in
my application or for paying the heating/electric costs for any future permanent residence I may move to in Wisconsin.

4. I understand I have the right to apply for Energy Assistance benefits and to receive either a payment or letter of explanation
within 45 days from the date the application process is completed. I understand that the payment or letter of explanation may
be delayed depending on when the Program year begins and/or when payments are being processed.

5. I understand I have the right to request a fair hearing within 15 days after receiving a notification letter if I believe my Energy
Assistance application has not been processed timely, has been incorrectly denied, or my payment is incorrect. I may also
request a fair hearing if I have not received payment or explanation. I may ask for a fair hearing by contacting the local office
that processed my application because I applied directly to their office or submitted an online application.

6. I understand I have the right to file a complaint if I believe I have been discriminated against in any unlawful way. I may file a
complaint by contacting the authorized person within my county or tribe or submit an email to [email protected].

7. I understand that by providing application information I am authorizing the Wisconsin Department of Administration and its
authorized agents to verify the data provided against federal, state, county, energy provider, water utility, employer and
landlord databases or records.

8. I understand that by providing the account numbers for my household energy supplier(s) I am authorizing the energy
provider(s) to provide details about the account and energy use to the Wisconsin Department of Administration for the
purposes of eligibility determination of this and future applications, benefit determination, and program evaluation and analysis
including before and after receiving any weatherization services.

9. I understand that the rights, requirements, and authorizations I am certifying to, may also apply to multiple heating seasons,
crisis, and furnace applications, when supplemental benefits are issued, and to outreach activities.

10. I understand the information collected on this and any future forms may be disclosed to energy programs operating under the
Wisconsin Public Benefit Program Authority, Wisconsin Public Service Commission Approval, or other programs administered
by the State of Wisconsin and may be used for the purposes of referral, research, evaluation, and analysis.

11. I understand if eligible for energy assistance benefits, I may be referred to other residential weatherization and/or energy
programs. I authorize the weatherization agency to provide weatherization services to my residence. If I am not the owner of
the residence, I authorize the weatherization agency to contact my landlord and I will cooperate with the agency providing
weatherization services.

12. I understand when applying for energy assistance I may be denied benefits and/or be required to apply online or via phone if I
demonstrate threatening behavior to an agency and/or worker.

I certify that all information provided in connection with the Wisconsin Home Energy Assistance Program application are true and
complete statements of facts. I further certify that I have read and understand the statements above. I understand that I may be
required to provide proof of any information upon request of an authorized agent of the Wisconsin Home Energy Assistance Program,
that giving false information will invalidate this and any future application(s) and require the return of any benefits received and possibly
subject me to criminal prosecution. By typing my name in the ‘Applicant Signature’ field, I indicate that I am the person named, and this
entry is the legal equivalent of a manual/handwritten signature. I further understand that I may print out the document and sign by
hand.
Applicant Signature Date (mm/dd/yyyy)

Applications must be mailed to the local energy office

Local office address: To contact your local office, go to:
https://energyandhousing.wi.gov/Pages/Home.aspx

Select the county/tribe where you live from the map

or drop-down menu found on this page.
This application can be made available in alternate formats to individuals with disabilities upon request.
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