ASSISTED HOME PERFORMANCE WITH ENERGY STAR

Transcription

1 ASSISTED HOME PERFORMANCE WITH ENERGY STAR Income Eligibility Application Thank you for your interest in the Focus on Energy Program! Please complete Sections 1 through 5 of this Income Eligibility Application for review and approval of eligibility for the Assisted Home Performance with ENERGY STAR Program. Applicants must provide complete, accurate and comprehensive information regarding household income and all individuals living within your household. Keep a copy of your completed application to retain for your records. See Pages 5 7 for additional guidance on completing this form. For Internal Purposes Only: Date and Time Received: Approved Income Level: Customer Service Rep Name: Income Eligibility Approval #: Please Note: Income verification and approval is required for participation in the Assisted Home Performance with ENERGY STAR Program. All applicants are required to complete income verification prior to payment of an incentive. Questions? Contact us at Section 1: Customer Information I am interested in: Referring Contractor (if applicable): q Assisted Home Performance with ENERGY STAR Rewards (Air Sealing and Insulation) First Name: Last Name: Date of Birth: Installation Address: City: State: WI Zip: Gas Utility: Gas Utility Account Number: Electric Utility: Electric Utility Account Number: Fuel Used for Space Heating: q Natural Gas q Propane q Oil q Electric q Other: Is this an: (New construction is not eligible for these rewards) q Existing Home q New Construction Property Type: (Only single family dwellings and multi-family dwellings with 1-3 units are eligible for these rewards. Property must be owner-occupied.) q Single Family q Multi-Family 1-3 Units q Other: Section 2: Applicant contact Information (Applicants will be notified of Income Eligibility by Phone or , followed by letter sent via U.S. Mail) First Name: Last Name: Mailing Address (If Different From Above): City: State: Zip: Phone: Preferred Method of Initial Contact: q Phone q Section 3: Application Signatures (Please read the entire application and sign) By signing and submitting this income eligibility application, the Applicant hereby certifies that he/she has read, agrees to and has met all Terms and Conditions and Program Qualifications as outlined in this application. The Applicant further certifies that all of the information contained in this application and supporting documentation is complete, true and correct, and all household income has been fully disclosed. If the Applicant differs from the Customer listed in Section 1, the Applicant is signing and certifying on behalf of the Customer, and certifies that he/she has been granted authority by the Customer to submit this Application and all supporting documentation. Applicant Signature: Print Name: Date: Please attach the following documents to your completed and signed Income Eligibility Application (all forms are required, unless otherwise noted): q Copy of most recent electric and natural gas utility bill. q Income Support Documents (include a support document for each income item listed in Section 5) Please Note: Black out all Social Security Numbers listed on documentation. Form Submittal - Return signed, completed Income Eligibility Application and all supporting documentation to: Mail: Focus on Energy Income Eligibility, 2821 Dairy Drive, Suite 5, Madison, WI wisconsinassistedhomeperformance@csgrp.com Questions: MM of 7

2 Section 4: Resident information List every eligible household member currently living at the installation address on Page 1. A household member is anyone who, on the date of submitting this application, is currently living in the household (with the exception of ineligible household members, as defined on Page 5). This includes persons related or unrelated. Any individual living in a housing arrangement and sharing common spaces is considered a household member for this application. Use the following instructions and additional information provided on Pages 5-6 for assistance when completing this table. Name: Enter the full name (First Name, Middle Initial/Name and Last Name) of each household member. Birth Date: Enter the birth date of each household member (mm/dd/yyyy). Child in Shared Custody? Select Yes in the Child in Shared Custody? field if the individual listed is a child who lives in more than one household because of a shared physical custody arrangement with an individual living outside of the household. Select No if this situation does not apply. Disabled: Select Dis. if the individual is disabled. Categorically Eligible: Select Cat. if the individual is categorically eligible. An individual is categorically eligible if he/she has been the recipient of FoodShare (FS, same as Food Stamps), SSI (Social Security Supplemental Income or Care Taker Supplemental Income, C-SUPP), or TANF/W2 (Wisconsin Works/Temporary Assistance for Needy Families) income for all of the previous 3 months to date of this application Name: Birth Date: Child in Shared Custody? Disabled or Cat. Eligible: (Select all that apply) 2 of 7

3 Section 5: Income Information List all income for each eligible household member who is part of the Economic Unit (with the exception of Ineligible Individuals for Income Purposes, as described on Page 6). An Economic Unit includes all individuals, related or unrelated, who live together in the household and jointly share in providing or being provided for the necessities of life (shelter, heat and utilities) for the household members. Applicants are required to fully disclose all eligible household income. Applicants must provide either three months or annual income (gross income), depending on the Income Types included in the table below. Income Support Documents: Documentation, including but not limited to paycheck stubs, employer letter of income, Social Security award letter, Letter from the Social Security office with information on benefits, most recently filed tax record and/or an IRS Form 1099, must be submitted with this application for each income item listed in the table below. Please provide a brief description of the documentation being attached to this application in the column Support Document for each income item listed. This information is used to determine if the household s total income level is eligible, within the 60% to 80% of the State Median Income requirement for the Assisted Home Performance with ENERGY STAR Program (included on Page 5). For more information on these Income Types and completing this section, please see Pages 6-7. (A) Alimony Received (G) Gambling/Lottery/Bingo (R) Rental Income* (SU) Sub Housing Utility Allowance (CS RECD) Child Support Received (GR) General Relief (SE) Self-Employment* (T) TANF/W2 (CS Paid) Child Support Paid (GF) Gifts/Donations (SS) Social Security (TR) Tribal per Capita* (C-Supp) SSI Caretaker Supplement (GV) Government Relief or Disaster (SSDI) Social Security Disability Income (US) Unemployment Compensation*** (DL) Disability Long-Term (LC) Land Contract Payment** (SP) Spousal Impoverishment (V) Veterans Benefits (DS) Disability Short-Term (O) Other (SSI) Social Security Supplemental Income (W) Wages & Tips*** (D) Dividends/Interest* (P) Pensions, Annuities, and IRA s* (SSI-E) Deduction (WK) Workers Compensation * This income type is based on the average of the prior 12 months of income. A copy of tax records and/or IRS Form 1099 must be provided with this application. ** Only the interest income received is counted. A copy of the amortization schedule or the IRS Form 1099 issued for tax purposes must be provided to complete this application. *** If the household member is a seasonal employee (a person whose main source of income is earned in less than 12 months of a calendar year), the annual income must be provided for both wages and unemployment compensation received in the prior tax year. Copies of IRS Form W2 and IRS Form 1099 must be provided to complete this application. Include only one Income Type per line. Do not include the income of any of the Ineligible Individuals for Income Purposes, as described on Page 5, in the table below. Household Member s Name: Income Type: Income Source: Previous Three Months of Income (Gross) Month 1 Month 2 Month 3 3 Month Total: Total 3 Month Household Income: Income Support Document: 3 of 7

4 Offer Availability n The Assisted Home Performance with ENERGY STAR Program is valid for installations between January 1, 2013 and December 31, n If an Applicant receives income eligibility approval following submittal of this application, the approval is valid for participation in the Assisted Home Performance with ENERGY STAR Program for installations completed within 12 months of the notification date. Any Applicant who fails to submit a Assisted Home Performance with ENERGY STAR Reward Application for qualifying installations within that period will be required to resubmit an Income Eligibility Application. n Submittal of a Assisted Home Performance with ENERGY STAR Reward Application does not guarantee payment of a reward. All requirements listed on the Assisted Home Performance with ENERGY STAR Application must be met to be eligible for rewards. Applicants who do not obtain pre-approval of income eligibility assume all liability if he/she is deemed ineligible for the Assisted Home Performance with ENERGY STAR Program. n All applications must contain current, complete and accurate information based on the date of application. n Income Eligibility Applications will be processed within 3 business days from receipt of the application if all necessary documentation is included. Applicants will be notified of income eligibility or denial by phone or , followed by a letter of income eligibility notification sent via U.S. Mail. n Only owner-occupied single family dwellings and multi-family dwellings of 3 units or less are eligible for the rewards included in the Assisted Home Performance with ENERGY STAR Program. Incentives may be available for other customer or property types. Please visit focusonenergy.com for other offerings and applications. n Applicants who are not eligible for the Assisted Home Performance with ENERGY STAR Program will be denied the rewards listed on the Assisted Home Performance with ENERGY STAR Reward Application. Applicants who do not qualify for the Assistance Program may be eligible for the Home Performance with ENERGY STAR Program Rewards. Ineligible applicants will be contacted following review of the Assisted Home Performance with ENERGY STAR Income Eligibility Application to determine eligibility for other rewards. n Incomplete applications cannot be processed. Failure to complete the income eligibility application in full and provide the required supporting documentation will either delay the income eligibility process or result in your application being denied. Receipt of an application does not guarantee approval of income eligibility or payment of an incentive. Program Qualifications You are only eligible to participate in the Assisted Home Performance with ENERGY STAR Program from the Focus on Energy program if you are: n A current residential customer of a participating utility in Wisconsin at the time of the installation and meet the income requirements set forth below. n At least 50% of home must be heated through natural gas or electricity. n The owner and resident of the home where eligible measures are being installed. Applicants must submit proof of ownership with this application, as listed on Page 1. Call if your situation differs from the requirements listed above. Customers will be reviewed for eligibility on a case by case basis. Please Note: Approval of income eligibility is required for the rewards included in the Assisted Home Performance with ENERGY STAR Reward Application and Applicants are strongly encouraged to complete the income eligibility process prior to submitting a Reward Application. Income Eligibility Requirements: n Applicants must have documented income between 60% and 80% of the State Median Income, as listed in the table on Page 5, to participate in the Assisted Home Performance with ENERGY STAR Program. Review and verification of income eligibility is required prior to payment of a reward. n Applicants with documented income greater than the 80% SMI value listed in the table on Page 5 for his/her household size may be eligible to participate in the Home Performance with ENERGY STAR Program. Applicants with income less than the 60% SMI value listed for his/her household size may be eligible for greater assistance rewards through other agencies. n Income eligibility is determined by the previous three month income values (gross) for all household members (unless otherwise noted on Page 3, as specific income types require 12 months of gross income, verified by an IRS Form 1099 or other Income Support Documents). The current rules at the time of application submittal for counting household income in the Wisconsin Home Energy Assistance Program and Operations Manual, and the Wisconsin Weatherization Program Manual will be used when determining income eligibility. n Applicant must report the names of all eligible household members (as defined on Page 5) living at the installation address at the time of application submittal. Applicant must fully disclose all income for each household member who is considered a part of the Economic Unit on Page 3, unless the individual is considered ineligible for income purposes (as noted on Page 6). Additional Requirements: n Applications must be completed in full and signed by the Customer, or an Applicant who is signing on behalf of the Customer. n All required supporting documentation listed on Page 1, including copies of electric and natural gas utility bills, proof of property ownership and income support documents for all income items listed on Page 3. Please Note: Applicants must black out all Social Security Numbers on documentation submitted with applications. Handling and storage of personal information, applications and all supporting documentation follow strict security and data handling measures similar in scope to the requirements of Wisconsin Home Energy Assistance Program (WHEAP) and Low Income Home Energy Assistance Program (LIHEAP). 4 of 7

5 State Median Income (SMI) Limits by Household Size (2013) Annual Income 3 Month Income Household Size Lower Limit: 60% SMI Upper Limit: 80% SMI Lower Limit: 60% SMI Upper Limit: 80% SMI $24,282 $31,754 $39,225 $46,697 $54,168 $61,640 $63,041 $64,442 $65,842 $67,243 $68,644 $70,045 $32,376 $42,338 $52,300 $62,262 $72,224 $82,186 $84,054 $85,922 $87,790 $89,658 $91,526 $93,394 $6,071 $7,939 $9,806 $11,674 $13,542 $15,410 $15,760 $16,111 $16,461 $16,811 $17,161 $17,511 $8,094 $10,585 $13,075 $15,566 $18,056 $20,547 $21,014 $21,481 $21,948 $22,415 $22,882 $23,349 How to Use This Chart: Income eligibility is determined using the documented income of the previous 3 full months. Certain income types required 12 months, which will be used to calculate a monthly average to determine the 3 month income value. Applicants must have a 3 month income of no more than the Upper limit: 80% SMI listed for his/ her household size in the table above. Applicants with income greater than the upper limit may be eligible for the Assisted Home Performance with ENERGY STAR Program. Applicants with income less than the Lower Limit: 60% SMI income value listed for his/her household size may be eligible for greater assistance rewards through other agencies. Applicants are encouraged to contact their local weatherization agency/office for more information on programs available to households with income less than 60% of the State Median Income. Terms and Conditions By submitting this application, the signatory(ies) and applicant(s) agree to all of the following terms and conditions. n Applicant certifies that the information contained in the application and all supporting documentation provided is true and complete statement of facts. The Applicant may be required to provide proof of any information on this application and that giving false information will invalidate this application, require the return of any rewards received and could possibly subject the Applicant to criminal prosecution. n Applicants submitting a reward application who have not been pre-approved for Income Eligibility assume all risk, as he/she may not be approved for participation in the Assistance Program and therefore ineligible for the rewards listed on the Assisted Home Performance with ENERGY STAR Application. n Income Eligibility approval does not guarantee payment of a reward. Applicants must meet all other requirements to be eligible for a reward. n All installations are subject to verification inspection by the Program to ensure the measures were installed properly. Participants must allow, if requested, the Program or a program representative reasonable access to their home to verify the installed measures. n The Program will only pay one reward per assessment. Rewards paid on this application cannot be claimed on another Focus on Energy application. Similarly, rewards can only be paid to one person or entity (i.e., either the resident or contractor, not both). n The program is not responsible for items (i.e. income eligibility applications, supporting documentation, reward applications, reward checks) lost or damaged in the mail. Continued on Page 6 5 of 7

6 Application Guidance, Continued Section 5: Income Information n How to complete the Income Information Section: Income of all members of the household who are part of the Economic Unit, as defined on Page 3, must be listed in Section 5: Income Information. o Household Member s Name: Enter the name of the household member for the income item you are listing in that row. o Income Type: Enter the Income Type, selecting a code, i.e. (A), from the Income Type table on Page 3. o Income Source: Enter the name of the employer, pension payer, self-employment, or the source of other types of income. o Months: Please write which months you are submitting income information for at the top of these columns in the spaces provided. Enter the monthly income for each income type for the previous 3 full months. (For example, if you are submitting your application in the month of May, you must provide income for the months of February, March and April). If you are submitting an income type that requires 12 full months of income information, as noted on Page 3, please leave the Month fields blank. Monthly income estimates will be determined by the program using the income support documents to calculate the average monthly income. o 3 Month Total: Sum the 3 month total income for each income item you have listed. o Income Support Document: List the supporting document you are submitting as an attachment to the application (i.e. paycheck stub or an IRS Form 1099). You must submit a supporting document for each income item for verification purposes. n Ineligible Individuals for Income Purposes: The income of the following individuals should not be included in Section 5: Income Information. o All individuals who are considered ineligible household members in the list above, under Section 4: Resident Information. o The earned income of minors under the age of 18 (or full-time high school students). n Income Types: The following provides explanation for each Income Type listed on Page 3 (Section 5: Income Information). o (A) Alimony Received: Payment(s) received from a former spouse. o (CS RECD) Child Support Received: Money received for child support by the parent who does not have full custody of the child (include money required by court order or voluntarily paid). o (CS Paid) Child Support Paid: Court ordered payment(s) for child support from the parent who is an eligible household member who does not have full custody of the child may be deducted from the gross income. Voluntary payments cannot be deducted. o (DL) Disability Long-Term: Payments made by an employer or insurance company for a permanent disability or medical condition. o (DS) Disability Short-Term: Payments made by an employer or insurance company for a temporary disability or medical condition. o (D) Dividends/Interest: Money that is received/earned in any of the twelve months prior to application and a household member has access to withdraw the money without penalty. (Examples of interest that might not be accessible: IRA s, CD s, etc.) o (G) Gambling/Lottery/Bingo: All income received from gambling, lottery, or bingo activities. Do not deduct losses. o (GR) General Relief: Money received from a tribal or county-funded program that provides financial assistance to adults who are ineligible for federal or state programs. o (GF) Gift/Donations: Money that was given to pay bills from another person, company or organization. This money does have to be paid back. In the Income Source field, list who gave this gift. o (GV) Government Relief or Disaster: Money paid to people who do not qualify for other types of public assistance. o (LC) Land Contract Payment: Provide only the interest received from the land contract payment. Use the amortization chart from the agreement, or the amount from the 1099 listed on the most recent tax form divided by 12. o (O) Other: Any other income received that is not listed above. Enter the type of income in the source field. A description in the Case Notes section is needed if using other. o (P) Pensions, Annuities, and IRA s: These payments are scheduled and paid on a regular basis. For pension or annuities paid on a monthly basis enter the amount paid each month. For those paid on a quarterly or other basis, enter the average monthly amount. Please provide most recent tax forms or 1099 form for verification. For railroad pensions or other federal pensions that have a medical premium deduction, subtract the amount up to the current Medicare Part B premium amount. o (R) Rental Income: Income received from rental purposes. This is a form of self-employment and must be reported as the net income received from the last 12 months, or prior tax year, divided by 12 for a monthly income amount. o (SE) Self-Employment: The annual income from self-employment reported on the self-owned business s tax forms. The gross annual amount is divided by 12 to get a monthly amount. If the business s recent taxes have not yet been filed, contact the local energy assistance agency for the appropriate forms o (SS) Social Security: Income received from Social Security because you or your spouse is retired. Report the awarded amount minus the Medicare Part B premium. Do not subtract any other deductions or premiums. o (SSDI) Social Security Disability: Income received from Social Security for long-term disability. This amount includes the social security survivor s benefits and ancillary benefits paid to children because of a deceased or disabled parent. o (SP) Spousal Impoverishment: The social security benefits designated to the community spouse when the other spouse is in a nursing home. The legally designated nursing home payment ($45) is not counted. o (SSI) Social Security Supplemental Income: Income paid by Federal Social Security (U.S. Treasury) and the State of Wisconsin for the elderly/ disabled. The Federal amount and State amount should be entered on separate income lines as two different incomes. o (SSI-E) Deduction: The additional State of Wisconsin SSI benefit issued to people who have an exceptional medical care need. This is itemized on the annual SSI benefit award letter. This amount can only be deducted if the person receives a higher amount from the State SSI program. o (SU) Sub Housing Utility Allowance: This is usually a reduction of rent for residents who live in subsidized housing for heating/electric use. This amount is provided by the local housing authority/landlord when the rent amount is determined. It may also be a cash payment made to the resident or the utility on behalf of the resident. o (T) TANF/W2: Cash payments received from Wisconsin s Temporary Assistance for Needy Families program - Wisconsin Works. o (TR) Tribal per Capita: A portion of this income is not counted. The annual and monthly amounts will be calculated by the program. Enter the name of the household member and the income type on Page 3 of the application, if the household member receives this income. Enter the Tribal per Capita income by household member in the Additional Notes section below. o (US) Unemployment Compensation: Payments received as part of unemployment benefits. An individual who is considered seasonal will need to report the UC income received in the prior tax year. The prior year amount is then divided by 12 to get a monthly income amount. Continued on Page 7 6 of 7

7 Application Guidance, Continued o (US) Unemployment Compensation: Payments received as part of unemployment benefits. An individual who is considered seasonal will need to report the UC income received in the prior tax year. The prior year amount is then divided by 12 to get a monthly income amount. o (V) Veterans Benefits: Income from VA Compensation, VA Pension (do not list as pension income), Retired Military Compensation, or Dependency and Indemnity Compensation (DIC). o (W) Wages & Tips: All gross wages and tip income received in the three months prior to the application month for all adults 18 and over living in the household who are part of the Economic Unit. Include all commissions, bonuses and profit sharing received in the last 12 months in the wage total. If the primary source of income for that individual is considered seasonal, you will need to provide copies of the W-2 s of all employment and the 1099 for the Unemployment received from the prior tax year. Seasonal employees are individuals whose primary employment is normally less than 12 months per year. The annual amount from each source will be divided by 12 to arrive at a monthly income amount. Please Note: Wage income for individuals under the age of 18 and those that are 18 and older currently enrolled in high school is not entered as counted household income. If a household member is under the age of 18 and has wage income, or is 18 or older and enrolled in high school, please explain in the case notes section. o (WK) Workers Compensation: Money received as an insurance benefit paid to an employee to replace wage income lost due to an injury in a work related incident. Additional Notes 7 of 7