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 or Rent_______ RENT/MORTGAGE 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 household 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.
2017 ENERGY SHARE GUIDELINES HOW TO APPLY
| FAMILY SIZE | ANNUAL INCOME LEVEL |
The Salvation Army is the local representative for Energy Share and is responsible for assessing need and determining eligibility for Energy Share assistance. To locate your local Salvation Army field representative, please call Carmen Lawson at (303) 866-9296. Applications are accepted from the first business day in December until the last business day of May each year. Extenuating circumstances may allow for funding outside of the dates mentioned above. Assistance is dependent on available funds. You must be a resident of Wyoming to qualify. CONTRIBUTIONS MAY BE MADE THROUGH THE SALVATION ARMY OR BY SENDING A CHECK TO: |
| 1 | $ 22,311 | |
| 2 | $ 30,044 | |
| 3 | $ 37,777 | |
| 4 | $ 45,510 | |
| 5 | $ 53,243 | |
| 6 | $ 60,976 | |
| 7 | $ 68,709 | |
| 8 | $ 76,442 | |
Each additional person add |
$ 7,733 |
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 Energy, City of Powell, Black Hills Corp, Align, Kelly Rizley Advertising & PR
| The Salvation Army PO Box 2948 Casper, WY 82602 307-234-2002 1-877-461-5719 |
The Salvation Army 601 E 20th St. Cheyenne, WY 82001 307-634-2769 |
The Salvation Army PO Box 61 Gillette, WY 82717 307-682-6982 |
The Salvation Army PO Box 2011 Sheridan, WY 82801 307-672-2444 |
For the quickest response, please submit copies of originals only. Please mail or hand deliver your application to the office closest to you.
