Energy Assistance Application

This online application should take anywhere from 5-20 minutes to fill out, depending on your household size. If we have remaining questions about your application, an Energy Assistance staff member will contact you. If you'd like to save your application and finish at a later time, please select 'Save' at the bottom of the page and you will be directed to create an account. In order to finish your application later, you'll need to save your username and password to log-in.

If you've already saved your application, please log in using the button below.

Save & Return

Use an account to return to saved work.

Please select the type of assistance:

Energy Assistance

Please select all of the following that apply to you or your household:

I Received Energy Assistance Last Year	I Received Food Assistance	I am a Tribal Member
I am Interested in Home Weatherization Services	I am Interested in Home Repair Services	I am interested in Rental Assistance
I am Interested in Free Preschool

Household Contact & Eligibility Information

Primary Applicant First Name *

Primary Applicant Last Name *

Primary Applicant Middle Initial

Social Security Number

DATE OF BIRTH (MM/DD/YYYY) +

Gender

Male

Female

Other

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Race

Education (24 Years or Older)

Disabled

Yes

No

Military Veteran

Yes

No

Health Insurance

Yes

No

Email *

Phone *

Residence Address

City

State

Zip

Is your mailing address the same as your residential address?

Yes

No

Mailing Address

City

State

Zip

How long have you lived at your residence?

Years

Months

HOUSING STATUS

Own/Buy

Subsidized

Rental

Roomer/Boarder

Cost per month?

HOUSING TYPE

Number of Bedrooms

Income/Benefits

Total number of people in household:

Is anyone in your household 60 years and older or have a disability?

Yes

No

Is anyone in your household 5 years old or younger?

Yes

No

Please select your primary HEAT source. (Select one only)

If you cannot provide proof of income, you will need to submit a Self-Request for Employment History and a Statement of Income. Do you need to submit a Self-Request for Employment History and Statement of Income? *

Yes

No

Social Security Income (SSI)	Temporary Assistance for Needy Families (TANF)	General Assistance (GA)
Veterans Assistance (VA)	Social Security Administration	Earned Income
Pension	Military	Child Support
Unemployment	Self-Employed	Other