Energy Assistance Eligibility Re-Verification Form

Energy Assistance Eligibility Re-Verification Form
Use this form to confirm whether your household still qualifies for energy assistance by providing updated contact, residence, household, income, and utility information.
Household and Contact Information
Applicant Name
First NameMiddle NameLast Name
Best Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Residence and Household Update
Current Service Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Number of People Currently in Household
Changes in Household Members Since Last Verification
Eligibility Re-Verification Details
Has your household income, employment, or benefit status changed since the last review?
If yes, briefly describe the change
Current monthly household income (USD)
Energy Account and Documentation
Utility Provider Name
Utility Account or Reference Number
Assistance Program ID or Case Reference Number
Upload Re-Verification Documents
Cancelof
Should be Empty: