Energy Assistance Program – Registration Form

About Energy Assistance Program

• Provides financial assistance to low-income households to maintain utility services during the winter heating season
• 2024-2025 program will include assistance with electric, heating, and water
• This assistance is for financially struggling families, and income qualification will be checked

Please complete the registration below.

Please note that this is only a registration/sign-up form. After completion, by first-comes-first basic, we will call you to give you the date and time for your appointment.

Mah hi Registration/Sign-up form lawng asi mu. First-comes-first basic in Appointment pek ding ah kan in (phone) awh than te lai.

ကျွန်ုပ်တို့ကို ဆက်သွယ်သည့်အတွက် ကျေးဇူးတင်ပါသည်။ ချိန်းဆိုထားသည့်အချိန်ကို ပေးရန်အတွက် ကျွန်ုပ်တို့သည် (First-comes-first basic) သင့်ထံ မကြာမီ ဆက်သွယ်ပါမည်။

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Name *

First

Last

Phone *

Email

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

How many people are in your family that live with you (your household size)? *

• 1 (I live alone)
• 2 (me and another person)
• 3 (me and another 2 person)
• 4 (me and another 3 person)
• 5 (me and another 4 person)
• 6 (me and another 5 person)
• 7 or more

Your available days and times (Please check one or any of your typical viabilities for the next several weeks). *

• Monday Morning (9:30-12:00 PM)
• Monday Evening (12:30-4:30 PM)
• Tuesday Morning (9:30-12:00 PM)
• Tuesday Evening (12:30-4:30 PM)
• Wednesday Morning (9:30-12:00 PM)
• Wednesday Evening (12:30-4:30 PM)
• Thursday Morning (9:30-12:00 PM)
• Thursday Evening (12:30-4:30 PM)
• Friday Morning (9:30-12:00 PM)
• Friday Evening (12:30-4:30 PM)

What is your language preference? (please list all the languages that you can speak and understand fluently)

Submit

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