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SUPERIOR WATERSHED PARTNERSHIPMICHIGAN ENERGY ASSISTANCE AP 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 20142015 energy crisis season. For example, a family of four with a monthly income level at or below 2,981may 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 outApplication and Intake Form (except signature areas).CALCULATION TO DETERMINE ELIGIBILITY:2014 Federal PovertyLevel (FPL) Guidelinesby Family SizeTotal gross household monthly incomeFamilySize100%Allowable expenses1 972.50Total gross income minus allowable expenses 2 1,310.833 1,649.17If applicable monthly medical expenses for medical hardship4 1,987.50Total gross income - allowable expenses - monthly medical expenses 5 2,325.836 2,664.17For eachadditionalpersonadd 338.00To determine FPL divide total gross income minus allowable expenses byfamily size household 100% FPL Amount” %Total income equals gross income minus allowable expenses (i.e. taxes, health insurance deductions, court-orderedchild support paid). Use total income from previous 30 days from date of application for calculation purposes.Note: Extenuating circumstances include medical hardship. An applicant can prove medical hardship by providing proof ofongoing 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? Yes No
2. Review all Eligibility RequirementsELIGIBILTY REQUIREMENTS: The utility account must be in the applicants name or an explanation must be provided. The applicantmust 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 receiveDHS 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 isnot 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 anundocumented alien exists in the household the amount of assistance will be prorated to exclude theundocumented 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 commercialaccount). Acceptable proof of residency includes, but is not limited to: MI Drivers License or State IDshowing 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 fuelcapacity.2014 Monthly Poverty Level GuidelinesFAMILY 3. After Application and Intake Form are complete, call your local St. Vincent de Paul (SVdP) Friends inNeed Office to set up appointment.4. Bring completed Application and Intake Form to appointment. Bring all required documentationincluding: itemized utility bill (must be past due to qualify for MEAP assistance) and shut-off notice ifapplicable, Social Security cards for everyone in the home; official State or Federal Identification for theApplicant; and all proofs of income (for past 30 days) from everyone in the home (income proofs mustbe no more than 60 days old). Applicant ID must be brought to the appointment. Applicant must signapplication at the appointment.Note: 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 allowfor 10 days after your appointment before contacting your SVdP office to check on the status of yourenergy assistance.
APPLICATION FOR SUPERIOR WATERSHED PARTNERSHIPMICHIGAN 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 usedin the determination of my eligibility. I also understandthat there may be adelaySTATEin processing if information is missing. For energy relatedAPPLICATIONFORemergencies, the MEAP crisis season runs from November1throughMay31.EMERGENCY RELIEFMichiganDepartmentof HumanServicesACCOUNT HOLDER INFORMATION (Name& Addressmust matchutility bill.If not, an explanation must be included.)Primary Account Holder NameSERVICE ADDRESSAddress (Number and Street Name, Apt., etc.)CityStateZip CodeCountyMAILING ADDRESS (If different than service address)Address (Number and Street Name, Apt., etc.)CityStateZip CodeCountyCONTACT INFORMATION:Phone number to reach youContact name and number to leave messagesEmail addressIf 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?YesYesNoNoIf so, was the energy assistance you received sufficient to avoid shut-off?YesNoIf the energy assistance you received was not sufficient to avoid shut-off, were you able to find additional funds?YesNoHave you received energy assistance services from this or any other MEAP agency below between October 1, 2014 – May 31, 2015?Yes (If yes, please check all boxes that apply)NoBarry County United WayConsumers Energy CompanyDHSDTE EnergyFlat River Outreach Ministries, Inc.Lighthouse Emergency ServicesMichigan Community Action Agency AssociationSEMCO Energy Gas CompanySociety of St. Vincent de Paul of the Archdiocese of DetroitSuperior Watershed PartnershipThe Heat and Warmth FundThe Salvation ArmyTrueNorth Community ServicesIf 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 agencyfor any energy assistance needed during the 2014 heating season. If a household works with another participating agency duringthe current energy heating season, SWP will deduct those payments from the 2,000 electric, gas, and wood cap or the 3,000 fueloil and propane cap.How do you heat your home?CoalElectricityFuel OilNatural GasPropaneWoodOtherHow 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?Yes, month receivedDo you receive (Check all that apply):Food StampsMedicaidHighest level of education completed:Trade SchoolAssociate DegreeDid not finish High SchoolHigh School DiplomaBachelor’s DegreeAdvanced DegreeOtherNoSER (State Emergency Relief)GEDSome CollegeREASONS FOR NEEDING ASSISTANCE (check all that apply):Crisis/unexpected expensesLow-income householdJob lossIllness/medical hardshipReceived maximum SER capReceived shut-off noticeServices are alreadyshut-offOther (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 tankNatural Gas Propane % remaining in tankOther Wood/Wood Pellets Is there any illegal or unauthorized usage occurring?Yes, reasonNoHOUSEHOLD 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 theysleep and keep their belongings in your home.NameRelationshipto youComplete SocialSecurity numberDate of birthAgeAccountHolderGender(M or F) Disabled? NoYesNoMove InDateMoveOutDateHOUSEHOLD INCOME– Attach extra pages if you need to include additional members. Does your household have income?Yes Total monthly household income Attach 30 days of proof from within the past 60 days.NoSocial Security benefits (RSDI)Supplemental Security Income (SSI)Pension/retirement benefitsVeteran’s benefits/military allotmentsDisability benefitsSelf-employment incomeUnemploymentChild supportEmployment/Earned IncomeWorkers CompensationMoney from family/friendOther, please list (ex: lottery winnings)Tribal Payments (Energy Assistance/LIHEAP) Date received: Amount received:Tribe: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 memberPerson With IncomeType of Income(If employed, name of employer)Adjusted Net MonthlyIncome(*deduct allowable expensesof employment from the gross)Projected Yearly Income(multiply adjusted netmonthly income by 12) Incomeverified?(Attach aCopy) Total Household Income *Adjusted Net income from employment of self-employment must be determined by deducting allowable expenses of employment from thegross amount received. Allowable expenses of employment include: mandatory withholding taxes (25% of gross), deductions required bythe employer as a condition of employment, deductions for health insurance, court-ordered child support, including arrears. No deductionis made for paid, voluntary child support.2
ADDITIONAL INCOME EXPENSES–Does the household pay any of the following expenses?Yes Check all that apply and ATTACH PROOFNoHealth 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 incomeENERGY EFFICIENCY OPTIONS (Choose one of the following):Check here if you would like a home energy check-upCheck here if you would like a home energy savings kitCheck here if you are not interested in receiving a home energy check-up or a home energy savings kitChoose one of the following (if applicable)Check here if you have previously received a home energy check-up from MEAPCheck here if you have previously received a home energy savers kit from MEAPSIGNATURE 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 thedetermination of my eligibility. I also understand that there may be a delay in processing if there is any missing information. I authorize theassisting agency to release any of this information to any agency for the purpose of research, study and evaluation of the MEAP. I understandthat missing information or failure to provide needed information may result in a delay or denial of my application. I understand that providingfalse 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 SVdPand SWP, its employees, volunteer, case workers, utility agents and grantors from any damages resulting from providing such information, Iagree 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 foridentity theft. By signing this form I confirm that the information provided is true to the best of my knowledge. I understand this procedure doesnot 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 IAM A THIRD PARTY APPLYING ON BEHALF OF ANOTHER PERSON, I SWEAR THAT THIS APPLICATION HAS BEEN EXAMINED BYOR READ TO THE APPLICANT.Signature of ApplicantDate:Authorized Representative (if applicable)Vincentian Name (please print):Vincentian Signature:Conference Name:Conference Code:Notes:3Date:Date:
CLIENT INTAKE FORM FOR SUPERIOR WATERSHED PARTNERSHIPMICHIGAN ENERGY ASSISTANCE PROGRAM (SWP MEAP)Intake Date: SVdP Representative: SVdP Conference:APPLICANT INFORMATIONName:Phone Number:Address:City: State: Zip Code: County:REQUEST FOR DELIVERABLE FUEL ASSISTANCEName of Utility/Vendor Request #2Name of Utility/Vendor Request #2Address of Utility VendorAddress of Utility VendorPhone Number of Utility VendorPhone Number of Utility VendorClient Utility/Vendor Account NumberClient Utility/Vendor Account NumberService Type: (check one) Electric Fuel Oil Propane WoodService Type: (check one) Electric Fuel Oil Propane Wood Natural Gas Other Natural Gas OtherDollar Amount to be Paid Using MEAP Funds:Dollar Amount to be Paid Using MEAP Funds: (Current Charges) (Current Charges) (Arrears/Past Due) (Arrears/Past Due) (Total Amount Requested) (Total Amount Requested)Are you on a payment/budget plan? Yes NoAre you on a payment/budget plan? Yes NoFOR SVdP USE ONLYWas a copy of the client’s itemized utility bill retained for the file? Yes NoAcceptable 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? Yes NoWere copies of all third party documents used to verify household income? Yes NoIs the household income at or below 150% FPL? Yes No This household is at the % FPLSignature 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, statisticalrecords, and all other pertinent records for the period of the grant term ending August 31, 2015.)4
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%
