SUPERIOR WATERSHED PARTNERSHIP MICHIGAN ENERGY ASSISTANCE PROGRAM www.superiorwatersheds.org/assistance.php MEAP assistance is for deliverable fuel only (electricity, fuel oil, natural gas, propane, & wood) In order to qualify for MEAP your family must be at or below the 150% poverty level during the 2014-2015 energy crisis season. For example, a family of four with a monthly income level at or below $2,981 may qualify for energy payment assistance. 1. Take home application and intake form. Determine whether your household is at or below the 150% poverty level before completing application. If your household is eligible, completely fill out Application and Intake Form (except signature areas). CALCULATION TO DETERMINE ELIGIBILITY: 2014 Federal Poverty Level (FPL) Guidelines by Family Size Total gross household monthly income $ Family Size 100% Allowable expenses - $ 1 $972.50 Total gross income minus allowable expenses = $ 2 $1,310.83 3 $1,649.17 If applicable monthly medical expenses for medical hardship - $ 4 $1,987.50 Total gross income - allowable expenses - monthly medical expenses = $ 5 $2,325.83 6 $2,664.17 For each additional person add $338.00 To determine FPL divide total gross income minus allowable expenses by family size household 100% FPL Amount % Total income equals gross income minus allowable expenses (i.e. taxes, health insurance deductions, court-ordered child support paid). Use total income from previous 30 days from date of application for calculation purposes. te: Extenuating circumstances include medical hardship. An applicant can prove medical hardship by providing proof of ongoing monthly medical expenses. These expenses can be deducted from the gross income to determine poverty level. Emergency bills or office visits do not qualify as medical hardship. Is the household income at or below 150% FPL?
2. Review all Eligibility Requirements ELIGIBILTY REQUIREMENTS: The utility account must be in the applicants name or an explanation must be provided. The applicant must be 18 years old or older and reside in the household. Total income in the household is at or below 150% of the Federal Poverty Level (FPL). If no income in the household, applicant must provide documentation showing they currently receive DHS benefits or sign a self-declaration form stating they have no income. Each member of the household must have a Social Security number and the number must be provided. A copy of the Applicant Social Security card must be submitted. Identity of the Applicant must be verified using a photo ID. Acceptable proof of identity includes but is not limited to: Driver s License, State-issued ID, School ID, Employment ID, or US Passport. Applicant must be a US citizen or qualified alien undocumented aliens are not eligible. However, if an undocumented alien exists in the household the amount of assistance will be prorated to exclude the undocumented alien. A fugitive felon in the household disqualifies the entire household. Residency of the Applicant must be verified (must be Applicant s primary residence, not commercial account). Acceptable proof of residency includes, but is not limited to: MI Drivers License or State ID showing current address, current utility bill, and/or lease/mortgage in Applicant s name. Maximum payment is capped at $2,000 for electricity, gas, and wood. Maximum payment is capped at $3,000 for fuel oil and propane. If applicant has received assistance from other MEAP-funded agencies during the current program year, they may still be eligible depending on the cap of the agency. A shut-off notice is not required, however the bill must be past due at the date the application is taken. For fuel oil and propane customers, the fuel tank must contain no more than 25% of its heating fuel capacity. 2014 Monthly Poverty Level Guidelines FAMILY SIZE 100% 120% 133% 135% 150% 1 972.50 1,167.00 1,293.43 1,312.88 1,458.75 2 1,310.83 1,573.00 1,743.41 1,769.63 1,966.25 3 1,649.17 1,979.00 2,193.39 2,226.38 2,473.75 4 1,987.50 2,385.00 2,643.38 2,683.13 2,981.25 5 2,325.83 2,791.00 3,093.36 3,139.88 3,488.75 6 2,664.17 3,197.00 3,543.34 3,596.63 3,996.25 7 3,002.50 3,603.00 3,993.33 4,053.38 4,503.75 8 3,340.83 4,009.00 4,443.31 4,510.13 5,011.25 3. After Application and Intake Form are complete, call your local St. Vincent de Paul (SVdP) Friends in Need Office to set up appointment. 4. Bring completed Application and Intake Form to appointment. Bring all required documentation including: itemized utility bill (must be past due to qualify for MEAP assistance) and shut-off notice if applicable, Social Security cards for everyone in the home; official State or Federal Identification for the Applicant; and all proofs of income (for past 30 days) from everyone in the home (income proofs must be no more than 60 days old). Applicant ID must be brought to the appointment. Applicant must sign application at the appointment. te: Utility bill stub is not sufficient, as it does not show the breakdown of the utility bill. 5. After your appointment, a SVdP representative will call with the status of your application. Please allow for 10 days after your appointment before contacting your SVdP office to check on the status of your energy assistance.
APPLICATION FOR SUPERIOR WATERSHED PARTNERSHIP MICHIGAN ENERGY ASSISTANCE PROGRAM (SWP MEAP) I hereby submit an application for the Michigan Energy Assistance Program (MEAP). I understand that the following information will be used in the determination of my eligibility. I also understand that there may be a delay in processing if information is missing. For energy related emergencies, the MEAP crisis season runs from vember 1 through May 31. ACCOUNT HOLDER INFORMATION (Name & Address must match utility bill. If not, an explanation must be included.) Primary Account Holder Name SERVICE ADDRESS Address (Number and Street Name, Apt., etc.) City State Zip Code County MAILING ADDRESS (If different than service address) Address (Number and Street Name, Apt., etc.) City State Zip Code County CONTACT INFORMATION: Phone number to reach you Contact name and number to leave messages Email address If applicable, reason name and/or address does not match utility bill: Is the household at or below the 150% poverty level? (See instructions for determining eligibility)? Have you received any energy assistance in the last 3 years? If so, was the energy assistance you received sufficient to avoid shut-off? If the energy assistance you received was not sufficient to avoid shut-off, were you able to find additional funds? Have you received energy assistance services from this or any other MEAP agency below between October 1, 2014 May 31, 2015? (If yes, please check all boxes that apply) Barry County United Way Consumers Energy Company DHS DTE Energy Flat River Outreach Ministries, Inc. Lighthouse Emergency Services Michigan Community Action Agency Association SEMCO Energy Gas Company Society of St. Vincent de Paul of the Archdiocese of Detroit Superior Watershed Partnership The Heat and Warmth Fund The Salvation Army Truerth Community Services If yes box is checked, please list date(s) and amount(s) for any services received from the above agencies: * It is anticipated that if a household works first with a MEAP service provider, the household will continue working with that agency for any energy assistance needed during the 2014 heating season. If a household works with another participating agency during the current energy heating season, SWP will deduct those payments from the $2,000 electric, gas, and wood cap or the $3,000 fuel oil and propane cap. How do you heat your home? Coal Electricity Fuel Oil Natural Gas Propane Wood Other How much have you paid towards your heating bill(s) in the past 6 months? (Do not include DHS or other agencies) $ Did you receive the Home Heating Credit in the last 6 months?, month received Do you receive (Check all that apply): Food Stamps Medicaid SER (State Emergency Relief) Highest level of education completed: Did not finish High School High School Diploma GED Some College Trade School Associate Degree Bachelor s Degree Advanced Degree Other REASONS FOR NEEDING ASSISTANCE (check all that apply): Crisis/unexpected expenses Low-income household Job loss Illness/medical hardship Received maximum SER cap Received shut-off notice Services are already shut-off Other (explain): 1
EMERGENCY NEED: check the service(s) you are requesting & the amount needed to resolve the emergency ATTACH PROOF * Payment for deliverable fuel will not be made if, at the time of delivery, it is confirmed you have more than 25% of fuel remaining in your tank. Delivery receipt must be submitted to the SWP for fuel oil, propane and wood. Electricity $ Fuel Oil $ % remaining in tank Natural Gas $ Propane $ % remaining in tank Other $ Wood/Wood Pellets $ Is there any illegal or unauthorized usage occurring?, reason HOUSEHOLD INFORMATION - Attach extra pages if you need to include additional members. 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. Name Relationship to you Complete Social Security number Date of birth Age Gender (M or F) Disabled? Pregnant? Citizen? Move In Date Move Out Date Account Holder HOUSEHOLD INCOME Attach extra pages if you need to include additional members. Does your household have income? Total monthly household income $ Attach 30 days of proof from within the past 60 days. 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 Veteran s benefits/military allotments Child support Other, please list (ex: lottery winnings) Tribal Payments (Energy Assistance/LIHEAP) Date received: Amount received: Tribal Payments (tribal GA, casino/gambling profit sharing, land claims, etc.) Rental income or a land contract, mortgage or other payment payable to a household member Person With Income Type of Income (If employed, name of employer) Adjusted Net Monthly Income (*deduct allowable expenses of employment from the gross) Projected Yearly Income (multiply adjusted net monthly income by 12) Income verified? (Attach a Copy) Total Household Income *Adjusted Net income from employment of self-employment must be determined by deducting allowable expenses of employment from the gross amount received. Allowable expenses of employment include: mandatory withholding taxes (25% of gross), deductions required by the employer as a condition of employment, deductions for health insurance, court-ordered child support, including arrears. deduction is made for paid, voluntary child support. 2
ADDITIONAL INCOME EXPENSES Does the household pay any of the following expenses? Check all that apply and ATTACH PROOF Health insurance premium (Covers what time period (1mo., 3 mos., etc.) Paid how often? $ Court ordered child support (amount paid per month) $ Actual child care costs paid by the employed person, not DHS $ Unusual employment related expenses. Explain expense: $ Ongoing monthly medical expenses. Attach proofs to Application $ *These expenses can be deducted from your gross monthly income ENERGY EFFICIENCY OPTIONS (Choose one of the following): Check here if you would like a home energy check-up Check here if you would like a home energy savings kit Check here if you are not interested in receiving a home energy check-up or a home energy savings kit Choose one of the following (if applicable) Check here if you have previously received a home energy check-up from MEAP Check here if you have previously received a home energy savers kit from MEAP SIGNATURE REQUIREMENT Please sign below with a SVdP representative as witness. Otherwise, this application will be incomplete. I hereby submit an application for the Michigan Energy Assistance Program and understand that the following information will be used in the determination of my eligibility. I also understand that there may be a delay in processing if there is any missing information. I authorize the assisting agency to release any of this information to any agency for the purpose of research, study and evaluation of the MEAP. I understand that missing information or failure to provide needed information may result in a delay or denial of my application. I understand that providing false information may result in fraud prosecution. I understand that my application may be selected for a complete review at any time. Authorization to Release: I authorize Saint Vincent de Paul (SVdP) and Superior Watershed Partnership (SWP) to review my account information, and I release SVdP and SWP, its employees, volunteer, case workers, utility agents and grantors from any damages resulting from providing such information, I agree not to hold SVdP or SWP responsible for any delay or loss of assistance due to incorrect or incomplete information or due to an error for identity theft. By signing this form I confirm that the information provided is true to the best of my knowledge. I understand this procedure does not imply that financial assistance will be granted. If assistance is denied I understand I may refer this to DHS for re-evaluation of eligibility. UNDER PENALTIES OF PERJURY, I SWEAR OR AFFIRM THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO ME. IF I AM A THIRD PARTY APPLYING ON BEHALF OF ANOTHER PERSON, I SWEAR THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO THE APPLICANT. Signature of Applicant Date: Authorized Representative (if applicable) Date: Vincentian Name (please print): Vincentian Signature: Date: Conference Name: Conference Code: tes: 3
CLIENT INTAKE FORM FOR SUPERIOR WATERSHED PARTNERSHIP MICHIGAN ENERGY ASSISTANCE PROGRAM (SWP MEAP) Intake Date: SVdP Representative: SVdP Conference: APPLICANT INFORMATION Name: Phone Number: Address: City: State: Zip Code: County: REQUEST FOR DELIVERABLE FUEL ASSISTANCE Name of Utility/Vendor Request #2 Name of Utility/Vendor Request #2 Address of Utility Vendor Address of Utility Vendor Phone Number of Utility Vendor Client Utility/Vendor Account Number Service Type: (check one) Electric Fuel Oil Natural Gas Propane Wood Other Dollar Amount to be Paid Using MEAP Funds: $ (Current Charges) $ (Arrears/Past Due) $ (Total Amount Requested) Are you on a payment/budget plan? $ Phone Number of Utility Vendor Client Utility/Vendor Account Number Service Type: (check one) Electric Fuel Oil Natural Gas Propane Wood Other Dollar Amount to be Paid Using MEAP Funds: $ (Current Charges) $ (Arrears/Past Due) $ (Total Amount Requested) Are you on a payment/budget plan? $ FOR SVdP USE ONLY Was a copy of the client s itemized utility bill retained for the file? Acceptable support includes: actual current itemized utility bill or screen print from the utility s website. Also include shut-off notice (if applicable). Was a copy of the applicant s official State or Federal Identification and a social security card obtained? Were copies of all third party documents used to verify household income? Is the household income at or below 150% FPL? This household is at the % FPL Signature Requirement Please sign below with a SVdP Representative as witness. Otherwise, this intake form will be incomplete. Applicant/Household Signature: Date: (By signing this form the applicant is stating all information is correct to the best of their knowledge.) SVdP Representative Signature: Date: (By signing this form the SVdP representative is stating that the agency will retain all financial records, supporting documents, statistical records, and all other pertinent records for the period of the grant term ending August 31, 2015.) 4