EnergyShare Application | Interfaith Community Outreach

Date*

Applicant Name*

First MI Last

Account Holder Name if Different

First MI Last

Address*

Street Address Address Line 2 City State ZIP Code

Telephone Number*

Email Address*

Total Number of People in Household*

People Over 60 Years of Age*

Head of Household is:*

Unemployed
Employed

(Employment Status Must be Verified)

Total Household Income is:*

(Salary Must be Verified)

Seeking Assistance for (Select One)*

Energy Supplier*

Energy Supplier Telephone Number*

Customer's Energy Supplier Account Number*

Do you have a Serious Medical on your Primary Energy Supplier's Account?*

No
Yes

Personal or Family Crisis (Explain)*

Statement of Application

I certify that the above statements and attachments are true and correct to the best of my knowledge, I understand that providing false information may result in disqualification of benefits. I understand that in requesting assistance from the Dominion Energy – EnergyShare programs, the information given above may be shared or given to other agencies to determine need and eligibility. By signing this form, I am allowing this agency to exchange information about me and my household with other agencies. Further, I authorize any social service, employment agency or my utility to provide confidential information to the EnergyShare Program and allow access to all of my account information up to and including usage information.

Applicant Signature*

Date*

FOR AGENCY USE ONLY

Applicant Number (if applicable)

Amount to be paid:

General
Veteran Pledge
Disabled Pledge

Referred to Weatherization:

Yes
No

Reason not referred:

Name

This field is for validation purposes and should be left unchanged.

Statement of Application

FOR AGENCY USE ONLY

Hours

Pages

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