Online: Mail or in person: The Heat and Warmth Fund, 535 Griswold, Suite 200, Detroit, MI 48226

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1 Dear Friend, The Heat and Warmth Fund (THAW), a leading provider of utility assistance, wants to make it easier for you to get the help you need. If you are a Detroit resident living in the following Zip Codes: and and you are struggling to pay your utility bill(s), you may apply for THAW Utility Assistance (Electricity, Heat, and Water) online at or by using a printable application. Apply for THAW assistance by: 1. Reviewing the Program Guidelines to see if you meet eligibility requirements. 2. Complete an application and include copies of all supporting documents. (Refer to the Document Checklist) 3. Mail or drop off the completed application to THAW for review and processing. Once THAW receives your completed application it will be reviewed and an approval or denial letter will be mailed to your home. If you are approved, the amount of assistance payment will be included in your letter. It may take up to 30 days for the assistance payment to be reflected on your utility account. Submit your application via THAW s website, mail or in person: Online: Mail or in person: The Heat and Warmth Fund, 535 Griswold, Suite 200, Detroit, MI We are here to help. If you have questions, please visit our website at or call THAW (8429) to speak to a THAW Utility Assistance Specialist. Thank you, Saunteel Jenkins Chief Executive Officer The Heat and Warmth Fund IMPORTANT Completing and/or submitting this application does NOT guarantee THAW utility assistance payment; does NOT prevent shut-off; and does NOT guarantee services will be restored. Assistance funds are limited and distributed on a first-come, first-serve basis. Incomplete applications or applications missing documents will not be processed.

2 Eligibility: 2016 Utility Assistance for Brightmoor Residents - Guidelines Applicant must be a City of Detroit resident Applicant must reside in or zip codes Applicant must have at least one child (18 or under) in the home; Proof of at least one minor child is required (shot record, report card, birth certificate, MDHHS Benefit Letter or enrollment verification that a minor child attends school in Brightmoor zip codes) Total owing cannot exceed $ for combined Heat and Electricity Total owing for Water cannot exceed $ Account must be in the applicant s name; if not the applicant must accept responsibility for the bill Account must be residential (not a commercial account) Applicant must pay for unauthorized usage and security fees Account must have a past due balance (usage arrearage) Proof of residency and responsibility for water account holder/applicant Household income must be at or below 200% of the 2016 Federal Poverty Level guidelines (See example chart below) Family Size: 1 Person 2 Person 3 Person 4 Person 5 Person 6 Person 7 Person Income: $1,980 $2,670 $3,360 $4,050 $4,740 $5,430 $6,120 *For each additional household member above 7, add $ per member Documentation Required for Electricity or Heat Assistance: Picture ID for applicant (Driver s license, or State ID) Copy of Social Security card for applicant Current (30 days) proof of income (paycheck stub, wage statement, SSI, SS, FIP) for all members of the household with income Proof of residency in or zip codes Additional Documentation for Water Assistance: Current DWSD water bill (or printout from the water department) If applicable, proof of responsibility for water account holder/applicant, Lease agreement or rental agreement that shows applicant is responsible for water payments

3 Please use this checklist to make sure you are including all appropriate information in order to process your application. Completion of this application does not prevent shut-off or guarantee that your services will be restored. Failure to provide supporting documentation will delay this process. Incomplete applications will not be processed. DOCUMENT CHECKLIST APPLICATION Completed THAW Application: Application MUST be signed by the account holder. x Copy of valid photo ID for account holder: (i.e. Driver s license or state issued ID) The address on the ID must match the service address on the account Copy of Social Security card for applicant: Social Security numbers for all household members must be included on the application Copy of 30 days proof of income for ALL members of the household: If there is no income in the household, you must sign Zero Income Affidavit (form included in this packet) Copy of your most recent DTE and or Water bill or printout/ statement from the water department: Only residential accounts are eligible If renting, lease or rental agreement showing applicant is responsible for water bill No commercial accounts DTE Bill City of Detroit Water Bill

4 2016 Utility Assistance for Brightmoor Residents Application Applicant Information: Social Security Number (need entire number): - - (Attach photocopy of social security card) First/Last Name: Phone Number: Address: City: Zip Code: County: Applicant s Date of Birth: Applicant s Gender: Male Female MDHS Case number (If applicable): Race: AA/Blk Arab Caucasian Hispanic Native American Other Have you received utility assistance from another agency in the last 12 months? Yes No If yes, name of agency: Date of assistance: Household Income: Please check all sources that apply and provide a copy of all third party documents used to verify household income: Social Security benefits (RSDI) Disability benefits Employment/Earned Income Supplemental Security Income (SSI) Self-employment income Workers Compensation Pension/retirement benefits Unemployment Money from family/friend Child support DHS Cash (FIP) Veteran s benefits/military Other, please list (ex: lottery winnings) allotments Rental income or a land contract, mortgage or other payment payable to a household member Total monthly household income $ Is the monthly household income at or below 200% of Federal Poverty Level? Yes No (See example chart below) Family Size: 1 Person 2 Person 3 Person 4 Person 5 Person 6 Person 7 Person Income: $1,980 $2,670 $3,360 $4,050 $4,740 $5,430 $6,120

5 Household Information (Continued): Total Number in Household: Number of Seniors (60 and over): Number of Adults (18-59): Number of Children (under 18): Number of disabled individuals in household? Number of pregnant individuals in household? Ages of Seniors: Ages of Children: List everyone who lives in your home, including adults and children temporarily absent due to illness or employment. People are considered members of your household if they sleep and keep their belongings in your home. Be sure to include date of birth and citizenship for each member. Attach extra pages if you need to include additional members. Age: Date of Birth: / / Social Security Number: - - U.S. Citizen: Yes No Age: Date of Birth: / / Social Security Number: - - U.S. Citizen: Yes No Age: Date of Birth: / / Social Security Number: - - U.S. Citizen: Yes No

6 Household Information (Continued): Do you receive (Check all that apply): Food Stamps Medicaid SER Do you own your home? Yes No Amount you paid toward your utility bill in the last 6 months $ (do not include assistance payment from DHHS or other agencies) Type of Household (where the applicant resides): Single Adult/No Children Single Parent/Minor Children Single Parent/Adult Children Single Parent/Minor and Adult Children Single Parent/Adult Child(ren) and Grandchildren Husband/Wife/No Children Husband/Wife/Minor Children Husband/Wife/Adult Children Husband/Wife/Minor and Adult Children Two Adults/Minor Children Other: Reason for Application (check all that apply): Received shut-off notice Crisis/Unexpected Expenses Loss of job Reduced wages/work hours Illness/Medical Hardship Received Maximum SER Services are already shut off Other: Education Completed: Some High School High School Diploma GED Trade School Some College Other: Associate Degree Bachelor s Degree Advanced Degree IMPORTANT: Applicant must sign below. Authorization to Release: I affirm the information provided is true, subject to verification, and if false, I will be denied THAW assistance. I understand that THAW Fund does not guarantee payment of funds, even if preliminary approval is granted. I hereby release THAW Fund, its employees, officers, directors and its partnering agencies from any liability in connection with the application and payment or nonpayment of any funds. I give permission to this agency, THAW and utility vendors to request and receive information from other parties as necessary to reach a determination on my request for utility assistance. I also understand that my information may be shared with funding agencies of THAW. I have read, understand and agree to these conditions and requirements. SIGNATURE REQUIREMENT Please sign below. Signature of applicant Date By signing this form, the applicant is stating all information is correct to the best of their knowledge

7 Applicant Name: Address: a. b. c. Rental income from real or personal property; d. e. Unemployment or disability payments; f. Public assistance payments; g. h. Sales from self-employment; i. Any other source not named above. Signature Date *Include a copy of DHHS award letter verifying active case status and services being received when completing this form I am self-employed in the business of: I have been self-employed in this manner since: / / previous year s tax return accountant s/bookkeeper s statement business receipts/check stubs other If none of the above is available, please state the reason why: Signature Date

8 Household Needs Assessment Questionnaire Needs Assessment Questionnaire THAW is requesting your completion of this questionnaire. Your responses will help us learn more about what you or members of your household may need in order provide you access to services that may provide additional resources for your household. THAW can connect you to resources or services in your area through our partner agencies. Please check all areas for preferred assistance/wraparound services: Clothing assistance Employment & Job Training Food pantry assistance Free Tax Preparation Disease Prevention Rental & Mortgage assistance Transportation assistance Weatherization Youth programming Daycare & Early childhood education Family Budgeting Mental Health Counseling Tutoring Education Other Emergency medical or financial assistance First Time Home Buying & Affordable housing Meals on wheels 1.) What is your preferred form of communication regarding wraparound services/programming? Telephone 2.) What other feedback would you like to provide on this needs assessment questionnaire? Thank you for your participation!