Complete por favor todas las paginas y envielas a nuestro correo postal: Home Energy

Transcripción

1 Dear Valued Customer: Eversource is offering free weatherization services designed to lower your energy bill. The HES-IE program is available to renters or homeowners with a GROSS income at or below 60 percent of the state median income. You may receive energy-saving compact fluorescent lightbulbs (CFLs), caulking, weather stripping and much more. Please complete all pages and return to us via mail. Our address: Home Energy Solutions Income Eligible, Eversource, P.O. Box 270, Hartford, CT Remember, if you rent, your landlord must complete the Owners Permission Statement. Your verification of income must be submitted along with the application. Also, please be sure to check each box on the form so your application can be processed without delay. Sincerely, The Energy Efficiency Team Eversource Respetable Cliente: La compañia Eversource esta ofreciendo servicios gratis de aclimatacion diseñados para ayudarle a reducer sus cuentas de energia. El Programa HES-IE esta disponible para inquilinos ó dueños con ingresos brutos al 60 porciento ó menos del promedio de ingresos del estado. Puede recibir bombillas fluorescente que ahorran energia, calafatee, burlete y mucho mas. Complete por favor todas las paginas y envielas a nuestro correo postal: Home Energy Solutions Income Eligible, Eversource, P.O. Box 270, Hartford, CT Recuerde, si usted alquila, su propietario tiene que completer la Declaracion de Permiso de Propietarios. Su verificacion de ingreso debe ser sometido juntamente con la solicitud. Tambien asegure de reviser cada seccion de la solicitud para que sea procesada sin demoras. Sinceramente, The Energy Efficiency Team Eversource

2 Owner s Permission Statement Free HES-IE Weatherization Services I am the owner or authorized agent of the residential building(s) located at: I hereby give permission to Eversource and Connecticut Natural Gas (CNG), or their authorized agents, to perform an energy conservation needs assessment and to install energy conservation measures at the above referenced location at no cost to me. Owner/Agent Address City, State, Zip Telephone Signature Print Name Date Authorized agents include the utility administrator, Community Action Agency weatherization department, or contractor hired to install conservation measures. Please return this form in the postage-paid envelope enclosed with the application or mail to: HES-IE Weatherization Services Eversource PO Box 270 Hartford, CT

3 HES IE Income Verification Statement Thank you for your interest in the HES IE Weatherization Service program. Before your application can be processed you will need to return this form with verification of your income. The following are valid forms of verification: * Copy of last four current paystubs * Work wages *Pension / Retirement * Proof of rental income if applicable * Proof of Unemployment * Proof of Social Security / Disability * Proof of State Assistance Be sure to return your income verification with the application. Energize Connecticut helps you save money and use clean energy. It is an initiative of the Energy Efficiency Fund, the Connecticut Green Bank, the State, and your local electric and gas utilities with funding from a charge on customer energy bills.

4 Application for FREE HES-IE Services READ AND COMPLETE ENTIRE FORM NAME / NOMBRE ADDRESS / DIRECCION CITY / CIUDAD STATE / ESTADO ZIP CODE / CODIGO POSTAL TELEPHONE NUMBER / NUMERO DE TELEFONO / CORREO ELECTRONICO BEST TIME TO CALL / MEJOR HORA PARA LLAMAR HOME TOTAL SQ. FT / TOTAL EN PIES CUADRADOS MORNING AFTERNOON EVENING TOTAL HEATED SQ. FT. / PIES CUADRADO CON CALEFACCION PLEASE COMPLETE ALL THAT APPLY: EVERSOURCE ELECTRIC ACCOUNT NO. EVERSOURCE GAS ACCOUNT NO. OIL COMP. NAME & ACCOUNT NO. CNG ACCOUNT NO. SCG ACCOUNT NO. PLEASE ANSWER ALL QUESTIONS BELOW. ALL INFORMATION IS STRICTLY CONFIDENTIAL. 1. I am a / Soy: Homeowner / Dueño Tenant / Inquilino NAME ADDRESS If you rent, you must print your landlord s / agent s name and address below. LANDLORD / AGENT MUST SIGN ATTACHED PERMISSION STATEMENT. CITY STATE ZIP CODE 2. Household information / Informacion de Casa: Total # of people in household: Num. of children / niños: Num. of elderly / anciano: Num. of disabled / incapacitado: 3. The total GROSS monthly income of all members in my household: Ingreso Total Mensual $ You are required to provide documentation to substantiate your income. Documentation may include pay stubs, social security check receipts and pension slips. Eversource reserves the right to verify income before services are provided. 4. My source of income is from: (check all that apply) Wages / Sueldo State Assistance Social Security / SSI Other 7. My heating source is: (check only one) Oil Electric Gas Propane Solar 8. My water is heated by: (check only one) Oil Electric Gas Propane Solar 9. My heating system type: (check only one) Hydro Air Furnace Baseboard / Radiant Geothermal Heat Pump Boiler 10. My cooling system type: (check only one) Central AC Heat Pump PTAC Window AC None 5. Received State Energy Assistance (provide copy of award letter): Recibio Asistencia de Energia Estatal (incluya copia de la carta) Yes No 6. I live in a: (check one only) Single Family 2-4 Units Townhouse / Rowhouse 5 + Units Mobile Home Condo For Office Use Only WO# / Date / Initials: CR REV I understand there will be no cost to me or my landlord / agent to receive these free weatherization services. I authorize my gas / oil company to release usage information to Eversource and its agents. I affirm that the information in this form is accurate. I understand that if the information is not correct, I may be charged for the conservation assistance I am provided by the HES-IE program. Please sign below: Signature / Firma: Date / Fecha:

5 Affidavit of Household With No Income Home Energy Solutions - Income Eligible Program (HES-IE) I,, affirm that no one over the age of 18 years who lives in my household, has had any income in the four weeks before the date I signed this affidavit. This means no adult in my household has received income from work, a pension, unemployment or worker's compensation, cash assistance from the Connecticut Department of Social Services (Temporary Family Assistance, State Supplement or the State Administered General Assistance program), benefits from the Social Security or Veteran's Administration, child support, interest, or any other income source. The following people live in my household: Name Check if person is under 18 years old I understand that the HES-IE program may request documentation regarding my income. I affirm that the information in this form is accurate. I understand that if the information is not correct, I may be charged for the conservation assistance I am provided by the HES-IE program. Name: Date: Phone Number: Energize Connecticut programs funded by a charge on customer energy bills

6 Declaración Jurada de Familia Sin Ingresos Soluciones de Energía Para El Hogar - Programa de Ingresos Elegibles (HES-IE) Yo, afirmo que nadie sobre la edad de 18 años que vive en mi casa, ha tenido algún ingreso en las cuatro semanas antes de la fecha firmada en esta declaración jurada. Esto significa que ningún adulto en mi hogar ha recibido ingresos de trabajo, una pensión, desempleo o compensación del trabajador, asistencia en efectivo del Departamento de Servicios Sociales de Connecticut (asistencia de familia temporal, suplemento estatal o el programa estatal de asistencia general), beneficios del Seguro Social o de veteranos, manutención, interés o cualquier otra fuente de ingresos. Las siguientes personas viven en mi casa: Nombre Verifique si la persona es menor de 18 años de edad Yo entiendo que el programa HES-IE puede solicitar documentación sobre mis ingresos. Afirmo que la información contenida en este formulario es correcta. Entiendo que si la información no es correcta, me pueden cobrar la asistencia de conservación recibida por el programa de HES-IE. Nombre: La fecha: Teléfono: Energize Connecticut programs funded by a charge on customer energy bills