SUPERIOR WATERSHED PARTNERSHIP MICHIGAN ENERGY ASSISTANCE PROGRAM www.superiorwatersheds.org/assistance.php Superior Watershed Partnership Michigan Energy Assistance Program (SWP MEAP) assistance is for heat-electricity, non-heat electricity, fuel oil, natural gas, propane, and wood for households that are at or below the 150% Federal Poverty Level. In order to qualify for MEAP your family must be at or below the 150% poverty level during the 2015-2016 energy crisis season. For example, a family of four with a monthly income level at or below $3,031.25 may qualify for energy payment assistance. 1. Determine whether your household is at or below the 150% poverty level before completing application. If your household is eligible, completely fill out the 2015-2016 SWP MEAP application. 2015 Federal Poverty Eligibility: FAMILY SIZE Monthly 150% Federal Poverty Level 1 $1,471.25 2 $1,991.25 3 $2,511.25 4 $3,031.25 5 $3,551.25 6 $4,071.25 7 $4,591.25 8 $5,111.25 Total income equals gross income minus allowable expenses (i.e. taxes, health insurance deductions, court-ordered child support paid). Provide total income from previous 30 days from date of application for calculation purposes. 2. Review all Eligibility Requirements (see next page) 3. After Application and Intake Form are complete, call your local St. Vincent de Paul (SVdP) Friends in Need Office, or other Partner Agency to set up an appointment. 4. Bring completed application to appointment. Include all required documentation including: itemized utility bill (must be past due to qualify for MEAP assistance), and shut-off notice, if applicable. Note: Utility bill stub is not sufficient, as it does not show the breakdown of the utility bill. Required at intake review: An official Social Security card for applicant; official State or Federal Identification for the applicant; and all proofs of income (from the past 30 days). Must have Social Security numbers and birth dates for everyone in the home. Applicant must sign and date the application at the appointment. 5. After your appointment, a SVdP representative, or other Partner Agency will call with the status of your application. Please allow 10 (ten) business days after your appointment before contacting your SVdP office to check on the status of your energy assistance.
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SUPERIOR WATERSHED PARTNERSHIP
MICHIGAN ENERGY ASSISTANCE PROGRAM
www.superiorwatersheds.org/assistance.php
Superior Watershed Partnership Michigan Energy Assistance Program (SWP MEAP) assistance is for heat-electricity,
non-heat electricity, fuel oil, natural gas, propane, and wood for households that are at or below the 150% Federal
Poverty Level.
In order to qualify for MEAP your family must be at or below the 150% poverty level during the 2015-2016 energy
crisis season. For example, a family of four with a monthly income level at or below $3,031.25 may qualify for energy
payment assistance.
1. Determine whether your household is at or below the 150% poverty level before completing application. If your
household is eligible, completely fill out the 2015-2016 SWP MEAP application.
2015 Federal Poverty Eligibility:
FAMILY SIZE Monthly 150% Federal Poverty Level
1 $1,471.25
2 $1,991.25
3 $2,511.25
4 $3,031.25
5 $3,551.25
6 $4,071.25
7 $4,591.25
8 $5,111.25
Total income equals gross income minus allowable expenses (i.e. taxes, health insurance deductions, court-ordered
child support paid). Provide total income from previous 30 days from date of application for calculation purposes.
2. Review all Eligibility Requirements (see next page)
3. After Application and Intake Form are complete, call your local St. Vincent de Paul (SVdP) Friends in Need Office,
or other Partner Agency to set up an appointment.
4. Bring completed application to appointment. Include all required documentation including: itemized utility bill (must
be past due to qualify for MEAP assistance), and shut-off notice, if applicable. Note: Utility bill stub is not sufficient,
as it does not show the breakdown of the utility bill. Required at intake review: An official Social Security card for
applicant; official State or Federal Identification for the applicant; and all proofs of income (from the past 30 days).
Must have Social Security numbers and birth dates for everyone in the home. Applicant must sign and date the
application at the appointment.
5. After your appointment, a SVdP representative, or other Partner Agency will call with the status of your application.
Please allow 10 (ten) business days after your appointment before contacting your SVdP office to check on the status
The applicant must 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).
All income verification must include the employee’s name, pay date and/or pay period, employer of source name,
gross amount of pay.
Pay Stubs: If paid weekly, must receive the most recent four consecutive pay stubs. If paid bi-weekly, must receive
most recent two consecutive paystubs.
SSI, Social Security, RSDI, SSDI and or Pension must provide current social security award or pension letter which
should include pages documenting any deductions. A bank statement must also be provided showing proof of
previous month’s deposit.
If no income in the household, applicant and all household members 18 and older must provide documentation
showing they currently receive DHHS benefits and/or must complete attached Zero Income Affidavit.
If self-employed, the household member must complete the attached Self-Employment Affidavit and include proofs
such as earnings from self-employment (receipts from an individual’s own business or from an owned or rented farm
after deductions for business or farm expenses), or Schedule C and current profit and loss statement as proof of
income.
Each member of the household must have a Social Security number and the number must be provided. A copy of the
applicants Social Security card must be submitted.
Identity of the applicant (not necessarily the account holder) must be verified using a photo ID. Acceptable proof of
identity includes but is not limited to: Driver’s License, State-issued ID, School ID, Employment ID, or US Passport.
Applicant must be a U.S. citizen or a qualified alien to be eligible.
Residency of the Applicant must be verified (must be Applicant’s primary residence, not commercial account).
Acceptable proof of residency includes, but is not limited to: MI Driver’s License or State ID showing current
address, current utility bill, and/or lease/mortgage in Applicant’s name.
A quote must be submitted with the application for fuel oil, propane, and wood pellets.
Maximum payment is capped at $3,000 for electricity, gas, wood, fuel oil and propane.
An approved applicant can only request assistance for the primary heat source.
If applicant has received assistance from the Low Income Home Energy Assistance Program (LIHEAP), DHHS or
other MEAP-funded agencies during the current program year, they may still be eligible depending on the cap of the
agency. Proofs of assistance must be provided. This is the responsibility of the applicant to provide this information.
A shut-off notice is not required; however, the bill must be past due at the date the application is taken (past due
charges must be shown on the bill). If the date is past the due date, but no past due charges are on the bill the client
can apply after the new bill with the past due charges is received. For fuel oil and propane customers, the fuel tank
must contain no more than 25% of its heating fuel capacity.
Late fees will not be paid to Michigan Public Service Commission (MPSC) rate regulated utilities.
A co-pay, if any, will be determined by the SWP staff during the application approval process. A letter will be sent to
the intake agency and to the applicant’s home address. Proof of payment must be provided within 30 days of
decision. The SWP will directly make payment to the Utility Provider within 10 (ten) days of received proof of co-
pay. Proof of payment may be emailed, faxed or mailed to the SWP by the client, intake representative, or the utility
provider.
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APPLICATION FOR THE 2015-2016 SUPERIOR WATERSHED PARTNERSHIP MICHIGAN 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 used in the determination of my eligibility. I also understand that there may be a delay in processing if information is missing. For energy related emergencies, the MEAP crisis season runs from November 1 through May 31. Applications may be accepted through summer months,
subject to funding levels. Revised 10/19/2015 (previous versions will not be accepted)
APPLICANT INFORMATION (Name & Address must match utility bill. If not, an explanation must be included.)
Applicant Name (Last name, First Name, Middle Initial)
SERVICE ADDRESS (Must match the address on energy bill)
Address (Number and Street Name, Apt., etc.) City State
Zip Code County
MAILING ADDRESS (If different than service address)
Address (Number and Street Name, Apt., etc.) City State Zip Code County CONTACT INFORMATION:
Phone number to reach you Contact name and number to leave messages E-mail Address
Have you received the Home Heating Credit? Yes No If no, please ask your intake representative on how to apply. Have you or do you currently receive benefits from Department of Health and Human Services (DHHS)? Yes No Is this your first request between October 1, 2015 and September 30, 2016 with the SWP MEAP Yes No If no, have you completed the budget counseling or submitted a certificate of completion or have you signed a waiver by the intake representative?
Yes No If no, your application will not be processed until a certification or waiver is submitted.
Have you received, or will you receive energy assistance services from this or any other MEAP-funded agency after
October 1, 2015? Yes, how much $________ No *Please provide approval letters with dates and amounts to verify information.
MEAP-funded agencies listed below: (please check all boxes that apply)
Barry County United Way Consumers Energy Company DHHS-Bureau of Community Action and Economic Opportunity
Downriver Community Conference DTE Energy Flat River Outreach Ministries, Inc. Lighthouse Emergency Services LIHEAP
Michigan Community Action Agency Association SEMCO Energy Gas Company Archdiocese of Detroit Society of St. Vincent
de Paul Superior Watershed Partnership The Heat and Warmth Fund (THAW) The Salvation Army TrueNorth Community
Services (EmPower)
If yes box is checked, please list date(s) and note the 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 agency for any energy assistance needed during the 2015-2016 heating season. If a household works with another participating agency during the current energy heating season, SWP will add those payments to the SWP MEAP cap, not to exceed $3,000 during the grant term.
ELECTRICITY Has your electricity been turned off? Yes, date power was turned off:____________________________________ No
Have you received a past due or shut off notice for your electricity? Yes, when is service scheduled to be shut
off?________________ No
HEAT Has your heat been turned off or have your run out of your only heating fuel source?
Yes, date heat was turned off or when fuel ran out:___________ No
Have you received a past due or shut off notice for your heat or are you at risk of running out of your household heating fuel?
Yes, number of days until fuel runs out or date service is scheduled to be shut off: ___________ No
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HOUSEHOLD 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 they
sleep and keep their belongings in your home.
Last Name, First Name, Middle Initial
Relationship
to You Complete Social Security
Number Date of Birth Age Disabled? Citizen?
SELF
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No Yes No
HOUSEHOLD INCOME– Attach extra pages if you need to include additional members. Does your household have income?
Yes Total monthly household income $______________ Attach past 30 consecutive days of proof. No
Is the household at or below the 150% poverty level? Yes No The Family FPL is __________%
Social Security benefits (RSDI) Disability benefits Employment/Earned Income
Supplemental Security Income (SSI) Self-employment income Workers Compensation
Pension/retirement benefits Unemployment Money from family/friend
Veteran’s benefits/military allotments Child support Other, please list (ex: lottery winnings)
Tribal Payments Date received:___________ Amount received:__________ Tribe:_______________________
Have there been any changes or do you expect a change in your household income in the next 30 days? Yes No Please attached explanation.
Please fill out income calculation worksheet before
Filling out these columns. Please note this is a projected amount for the next 30 days.
Person With Income
Type of Income
(if employed name of employer)
How often are you paid?
Gross income for next 30 days
(amount before taxes and expenses)
Allowable expenses (30 days)
Adjusted Net Income for next 30 days
Income verified? (attach a
copy)
$ $
$ $
$ $
$ $
$ $
$ $
$ $
Total Household Income $ $
*Adjusted Net Income from employment or self-employment must be determined by deducting allowable expenses of employment from the gross amount received.
Allowable expenses of employment include: mandatory withholding taxes (25% of gross), deductions required by the employer as a condition of employment, deductions
for health insurance, court-ordered child support, including arrears, and unusual employment related expenses. No deduction is made for paid, voluntary child support.
Please provide proof for all claimed expenses.
3
CLIENT INTAKE FORM FOR SUPERIOR WATERSHED PARTNERSHIP MICHIGAN ENERGY ASSISTANCE PROGRAM (SWP MEAP)
APPLICANT INFORMATION
Applicant Name: ___________________________________________ Name of account holder: _______ Service Address: ____________________________________________________________Phone: ________________________________ City: ___________________________________ State: _____ Zip Code: _______________ County: _______ Note: Customer co-pay may be required based on Federal Poverty Level (FPL)
Phone Number of Utility Vendor _________________________________________________________ Client Account Number _________________________________________________________
Request for Non-Heat Electric
Name of Utility/Vendor
Address of Utility Vendor
Phone Number of Utility Vendor _________________________________________________________ Client Account Number _________________________________________________________
Service Type: (check one) How much is needed to resolve the
☐Primary-Heat Electric emergency for 30 days? ____________
☐Natural Gas
☐Fuel Oil ______% remaining in tank
☐Propane ______% remaining in tank
☐Wood (face cords) ______# of face cords remaining
☐Wood (pellets) ______# of remaining bags
Service Type: How much is needed to resolve the
☐Non-Heat Electric emergency for 30 days? ____________
Dollar Amount(s) to be Paid Using MEAP Funds:
$ ________________________ Quoted Amount
(Attach quotes from energy providers for propane and fuel oil)
$ _________________________________ Past Due Charges
$ _________________________________ Current Charges
$ _________________________________ Late Fees
$_________________________________ Total Amount Owed
* 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. *Quote for deliverable fuel must be submitted with application.
4
Have you ever received a home energy savers kit? Yes No
If no, would you be interested in receiving a home energy savers kit? Yes No
Do you own your home? Yes No
If you own your home what weatherization measure(s) would give your home the greatest energy savings?
Wall insulation Energy efficient refrigerator
Attic insulation and ventilation Energy efficient boiler or furnace
Foundation insulation Energy efficient window replacement
Air leakage reduction Other: ____________________________________
If you are a qualified homeowner, do you wish to be contacted for potential weatherization assistance? Yes No
SIGNATURE REQUIREMENT
Please sign below after reading the following information, otherwise this application will be considered incomplete.
I understand I have 10 (ten) business days to provide all verifications requested and failure to provide the above information may result in denial of my application. I understand giving false information can result in referral to the prosecutor for fraud. I understand that my application may be one of those chosen for a complete investigation. An agency or department representative may call at my home and may contact other people in order to verify my eligibility for assistance.
I authorize the assisting agency or provider to release my name and address to the local weatherization operator as part
of the Weatherization Referral System. I authorize the department to release case and payment information to the
Department of Health and Human Services (DHHS), its affiliates and/or contracted agencies, for the purpose of
research, study and evaluation of the Low Income Home Energy Assistance Program (LIHEAP) and the Michigan
Energy Assistance Program (MEAP).
I authorize my energy company to release by phone, fax, email or their computer web site all available information about
my account.
I understand that after my first assist with the SWP MEAP I will have to complete a budget counseling session and
provide proof of completion, or have a waiver signed by an intake representative before applying for my next assist.
Customer co-pay may be required based on Federal Poverty Level (FPL).
UNDER PENALTIES OF PERJURY, I SWEAR OR AFFIRM THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO ME. IF I AM A THIRD PARTY APPLYING ON BEHALF OF ANOTHER PERSON, I SWEAR THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO THE APPLICANT. TO THE BEST OF MY KNOWLEDGE, THE FACTS ARE TRUE AND COMPLETE.
Signature of applicant: Date: Signature of spouse (optional): Date:
Address (Number & Street Name, Apt., etc.): Signature of Agency / Conference Representative:
Date:
Current phone number: Identification of applicant or authorized representative (optional):
Agency or Conference Code:
Request for Review If you believe any action of the agency is incorrect, or if the decision to approve or deny your application is not made within 10 (ten) days of the application date, you have the right to a hearing. A request for a hearing must be in writing, signed by you or your authorized representative, and received by the agency making the eligibility determination within 90 days following the date of this form.
To qualify for SWP MEAP Assistance, your household must be at or below the 150% Federal Poverty Level (FPL)
Income Proofs - what to submit with your application.
If you get paid weekly, bring your last four check stubs
If you get paid bi-weekly, bring your last two check stubs
If you get paid semi-monthly, bring your last two check stubs
If you get paid monthly, bring your last check stub (For Social Security, please provide your award letter
and your bank statement showing the deposit from the previous month).
If anyone in the household is 18 years old or older and does not have income, a zero income affidavit
must be signed by the household member and submitted with the application.
If anyone in the household is self-employed, documentation must be provided to support the income
and a self-employment affidavit must be signed and submitted with the application.
Instructions for determining earned and unearned income for the following 30 days.
Your application is ready to be submitted when all the information and documentation is included with the
application. This is the date you and your intake person will sign the application. This is day 1. On the next
page of this packet is a calendar. On the calendar circle day 1 (one) and count out 29 more days ahead. Now
circle your pay dates. Note: During certain periods you may receive an extra check during the 30 day period.
This is considered part of your income for the next 30 days.
Example: If you get paid weekly and during the upcoming 30 days you get 4 (four) paychecks then you would
add the gross earnings for all 4 (four) check stubs to get your gross pay. This amount will be your gross earn-
ings for the following 30 days. Please use income calculation sheets to determine any allowable deductions
from your gross.
If you get paid weekly and during the upcoming 30 days you get 5 (five) paychecks, then you would add the
gross earnings for all 4 (four) check stubs to get an average pay. You would then take that average and mul-
tiply by 5 (five) to get your projected earnings during the next 30 days.
This situation works the same way with bi-weekly, semi-monthly and monthly payments. You may find your-
self over the 150% Federal Poverty Level (FPL) during certain times of the year.
Income #VALUE!
(All Household Members) #VALUE!
#VALUE!
Add: Earned and Unearned Income
Total Monthly Household Income
Less: Allowable Expenses
Expenses: Total allowed expenses
Equals: Household New Income
Total Monthly Household Income minus (-) Allowable Expenses
SWP MEAP Eligible:
Is the household income at or below 150% FPL? (Provide Calculation below) #VALUE!
Example: Calculation
$926.38
Divided by Divided by
$980.83 = 94% FPL
%FPL
Total Family Members 0
1/0/00 to 1/29/00
$0.00
Calculation:
"Household Monthly Income"
Divided by
"Household 100% FPL Amount" = FPL %
#VALUE!
$1,327.50
$1,674.17
$2,020.83
$2,367.50
$2,714.17
$346.66
Court-ordered child support paid including arrears
Total Earned
Total Unearned
Withholding Taxes - Un-Earned Income (Enter Taxes Withheld on Income Verification forms)
$0.00
$0.00
Service Screening Instrument
$0.00Mandatory withholding taxes (25%) - Earned Income
Reductions for health insurance
MEAP Federal Poverty Level Worksheet
Income Calculation Form
Name Source/EmployerSelf or
Relation to SelfFrequency of Pay
Under 150% of Federal Poverty Level
Above 150% of Federal Poverty Level
No Income
30 Day Gross Income
$0.00Total Household Income
Typing your name and date in the space above signifies that you
certify you have verified the accuracy of the information contained in
this form
For each additional person add:
$0.00
2015/2016 Federal Poverty Level (FPL)
Guidelines by Family Size (Monthly)
Family Size
1
100%
Intake Worker Signature:
The cost of dependent daycare (up to $200 per qualifiing child)
$0.00
2
$980.83
3
4
5
6
Date of Application:
30 Day Income
Computation Period:
NOYES
Updated 10-24-14
This affidavit is to be signed by any individual who is 18 years of age and over who claims on the application to have no income.
Household Member Name(s): ______________________________________________________________
I hereby certify that I do not receive income from any of the following sources: a. Wages from employment (including tips, commissions, bonuses, fees, etc.); b. Income from operation of a business; c. Rental income from real or personal property; d. Social security payments, pensions, annuities, retirement funds, insurance policies, or death benefits; e. Unemployment or disability payments; f. Public assistance payments; g. Periodic allowances such as alimony, child support, or gifts received; h. Sales from self-employment;
i. Any other source not named above.
I certify that the information contained in this affidavit is true and accurate to the best of my knowledge.
Signature ______________________________________________ Date ___________________________________
Signature ______________________________________________ Date ___________________________________
Signature ______________________________________________ Date ___________________________________
Signature ______________________________________________ Date ___________________________________
**Each household member 18 years and older who has no income needs to fill out this form**
This affidavit is to be signed by any individual who is 18 years of age and over who claims on the application to be self-employed.
I am self-employed in the business of: _________________________________________________________
I have been self-employed in this manner since: ________/_______/__________
To the best of my knowledge, I estimate to earn
Estimated earnings is supported by: accountant’s/bookkeeper’s statement business receipts/check stubs schedule C and profit and loss statement other : ______________________________
If none of the above is available, please state the reason why: _______________________________________________
I certify that the information contained in this affidavit is true and accurate to the best of my knowledge.
Signature ______________________________________________ Date ___________________________________
