MAP Application Check List

Transcription

1 MAP Application Check List r Completed application (sign bottom of page 4) r Copy of most recent SEMCO Energy bill r Picture ID is required for the SEMCO account holder Driver s license, state identification card, or passport r If the picture ID does not reflect SEMCO service address, additional documentation is required to show proof of residency Other utility bill, cable bill, pay stub, etc. r Social Security cards are required for all members of household r Proof of income Must be from one month prior to applying for MAP program Sources may include any of the following: 3 Pay stubs 3 Employment letters/statements 3 Unemployment letters/statements 3 Social Security and pension letters/statements 3 Worker s compensation letter/statement 3 Child support verification 3 Friend of the Court letters/ statements or check stubs 3 Divorce decree 3 Check stubs/receipts 3 Disability letters/statements 3 Interest, annuity or dividend letters/statement 3 Federal or state tax forms Please understand that providing incomplete information within your submitted application packet will delay processing. MAP APPLICATION / CHECK LIST

2 MAP Application Form Fill out the forms in this application and attach and return supporting documents. Incomplete applications will take longer to process. Mail application back to The Heat and Warmth Fund for validation. Primary Account Holder Information SEMCO Energy Account Holder: First: Middle Initial: Last: Social Security Number: - - Date of Birth (mm/dd/yy): / / SEMCO Energy Account Number: Service Address: City: County: State: Zip: Mailing Address (if different than above) Street: City: County: State: Zip: Primary Phone: ( ) - Address: Please check the appropriate box: r MAP New Enrollee r MAP Reenrollee Have you received energy assistance services from any agency in the past 12 months? r Yes If yes, please provide the following: Assistance date: Assistance amount: $ Utility/energy provider: Energy assistance provider: Reason for needing energy assistance (check all that apply): r Limited income r Job loss r Medical hardship r Other Will the assistance being provided be for deliverable fuel? r Yes If yes, is the level of the fuel at or below 25% capacity? r Yes This application with all supporting documentation to be mailed back to THAW. Limited spots are available. Program filled on a first come first served basis. For more info call THAW s MAP line at Shelby St. Suite 400 Detroit MI MAP APPLICATION / PAGE 1

3 Household Information Total number of members, including the applicant, living in the households. List all below MAP APPLICATION / PAGE 2

4 Household Wage or Business Income Are you or another household member employed? r Yes If yes, complete the income verification table below. You must also provide proof of income. A full 30 days of paycheck stubs is required. The paycheck stub cannot be dated more than 60 days from the date signed on the application. First & Last Name Employer Pay Gross Earnings Proof Frequency (Before Taxes) Attached If reporting gross pay, 25% will be deducted for mandatory tax allowance. Do any of the household members receive income? r Yes If no, you must complete the No Income Affidavit and return it with your application. Attached Affidavit: r Yes Are any household members self-employed? r Yes If yes, each self-employed household member must complete the Self-Employed Attached Affidavit: r Yes Affidavit and return with application. Other Household Income Does anyone in your household receive an unearned income? r Yes If yes, complete the table below. Include proof of income with your application. Income Source Codes 1 Social Security 6 Supplemental Security Income (SSI) 11 Disability Benefits 2 Pension/retirement benefits 7 Worker s Compensation 12 Unemployment Compensation 3 Veteran s Benefits 8 Child Support (received) 13 Rental Income 4 Military Allotments 9 Tribal Payments 14 Section 8 Energy Subsidy Payments 5 DHS FIP Cash Assistance 10 Adoption Subsidy 15 Other Income Pay Amount First & Last Name Source Code Frequency Received Proof Attached $ r Yes $ r Yes $ r Yes $ r Yes MAP APPLICATION / PAGE 3

5 Eligible Expenses Does your household pay the following expenses? r Yes If yes, check all that apply. Include proof of expenses with your application. First & Last Name Monthly Expense Amount Paid Proof Attached r Health insurance premiums r Yes r Health insurance premiums r Yes r Health insurance premiums r Yes r Health insurance premiums r Yes I affirm the information provided is true, subject to verification, and if found false, I will not be enrolled in SEMCO Energy s MEAP Assistance Program (MAP). I understand that THAW Fund does not guarantee enrollment in the program, 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. 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 enrollment or to remain eligible in the MAP program. I have read, understand and agree to these conditions and requirements. Signature (SEMCO Energy account holder must sign the application) Date MAP APPLICATION / PAGE 4

6 Zero Income Affidavit Applicant Name: Address: I hereby certify that any person in my household does not receive income from any of the following sources: a. Wages from employment (including tips, commissions, bonuses, fees, etc.); b. Income from operation of a business; c. Rental income from real or personal property; d. Social security payments, pensions, annuities, retirement funds, insurance policies, or death benefits; e. Unemployment or disability payments; f. Public assistance payments; g. Periodic allowances such as alimony, child support, or gifts received; h. Sales from self-employment; i. Any other source not named above. I certify that the information contained in this affidavit is true and accurate to the best of my knowledge. Signature Date Self-Employment Affidavit This affidavit is to be signed by any individual who is 18 years of age and over who claims on the application to be self-employed. I am self-employed in the business of: I have been self-employed in this manner since: / / To the best of my knowledge, I expect to earn $ in the upcoming 12 months. This estimated earnings is supported by: r previous year s tax return r accountant s/bookkeeper s statement r business receipts/check stubs r other If none of the above is available, please state the reason why: I certify that the information contained in this affidavit is true and accurate to the best of my knowledge. Signature Date MAP APPLICATION / AFFIDAVIT