energyshareofwyoming.org
Physical Address: ________________________________Mailing Address: _____________________________City: ___________________Zip: _____________-
County: ___________________________Home Phone: _____________________ Message Phone: _______________________
Monthly Household Income: (verification of income is required) Wages/Salary $_________ TANF $ __________SS/SSI $__________ Child Support $_________
U.I. $ _____________ Food Stamps $ ____________ Other (please list source and amount) $_______________ List all Household members below
Last name / First Name Social Security # Relationship Date of Birth Occupation
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PLEASE CIRCLE YOUR
ANSWERS:
Do You: Own Rent RENT/PAYMENT: $___________ RECEIVED LIEAP? YES $ __________ NO ____________
Heating Fuel: Natural Gas Electric Propane Fuel Oil Wood Other: _____________
Received Energy Share before: Yes, When? ___________ No Assets (Cash, Checking, Savings etc.) $ __________ Applied Elsewhere? Y N Where? ____________
Medical Expenses paid this year: $_____________________
Please describe the circumstances that led up to your need to apply for Energy Share: (attach additional sheet if necessary) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________
A COPY OF YOUR MOST
RECENT BILL IS REQUIRED
Amount needed: $ _____________________________________ Vendor: ________________________________________
MONTHLY EXPENSES:
Rent/Mortgage $____________ Food $______________ Medical $ ____________ Taxes (home) $ ___________ Child Care $ _____________
Utilities $ _______________Car $________________Cable $ ________________ Phone $ _____________ Transportation $ ______________
Other $ ________________ Other $ _______________ Other $________________
DISCLOSURE STATEMENT
I certify
that the information provided is true, complete and correct. I understand that a false certification could
subject me to criminal charges, including fraud and/or receiving goods/services
under false pretenses. I, therefore,
authorize the release of any and all information deemed necessary by Energy
Share of Wyoming or its agents to determine the validity of my application.
APPLICANTS SIGNATURE:
_____________________________________________________________________________
DATE: _________________________________________________
Energy Share of Wyoming is a private, non-profit organization established
to help people in hardship circumstances with energy-related emergencies. It assists people with energy problems when
no other resources are available to them and when these problems are caused by
circumstances beyond their control.
The organization focuses on helping with energy/fuel-related emergencies.
Energy Share may help individuals pay their energy/fuel bills.
A one-time expenditure of up to
$400 per house-hold can be made to provide assistance.
First Priority goes to individuals and families with annual incomes at or
above 185% of the Poverty Income
Guidelines.
2016 ENERGY SHARE
GUIDELINES HOW TO
APPLY
FAMILY SIZE ANNUAL INCOME LEVEL
|
1 |
$ 21,978 |
|
2 |
$ 29,637 |
|
3 |
$ 37,296 |
|
4 |
$ 44,955 |
|
5 |
$ 52,614 |
|
6 |
$ 60,273 |
|
7 |
$ 67,950 |
|
8 |
$ 75,646 |
|
Each additional person add |
$ 7,696 |
SPONSORING
ORGANIZATIONS AND UTILITIES: The
Salvation Army, Montana/Dakota Utilities., Rocky Mountain Power, Black Hills
Energy, Townsquare Media Group, Wyoming
Rural Electric Assoc., City of Gillette, Powder River Energy Corp, Town of
Lusk, Dominion-Questar, City of Powell, Black Hills Corp, Align, Kelly Rizley
Advertising & PR
For the quickest
response, please submit copies of originals only. Please mail or hand deliver your application
to the office closest to you.
