ENERGY ASSISTANCE PROGRAMS APPLICATION JULY 2022 – MAY 2023
Ohio’s Energy Assistance Programs can help income eligible Ohioans manage their utility bills. The Home Energy Assistance
Program (HEAP), and emergency HEAP provide the benefit directly to a customer’s utility bill. The Percentage of Income
Payment Plan (PIPP) is an extended payment plan in which customers pay a percentage of their income toward their utility
bill each month. If you are looking to improve the energy efficiency of your home to help lower your energy bills, the Home
Weatherization Assistance Program (HWAP) or Electric Partnership Program (EPP) can help. For HWAP and EPP visit energyhelp.
ohio.gov to find your local provider and contact them for additional information
You can apply for the Energy Assistance Programs by visiting energyhelp.ohio.gov and completing the online application, by
completing this application and mailing it in, or by scheduling an appointment with your local Energy Assistance Provider or
HWAP/EPP provider. If you mail in your application or apply online, it can take up to 12 weeks to process.
Here’s what you’ll need to complete this application:
• Proof of citizenship for each household member
• Proof of income for each household member for the
previous 30 days or 12 months
• Copies of your most recent utility bills
• Disability verification (if applicable)
A household is defined as any individual or group of individuals who are living together as one economic unit for whom
residential energy is customarily purchased in common or who make undesignated payments for energy in the form of rent
(Per Section 2603 (5) of the Low-Income Energy Assistance Act of 1981). If you live in federally subsidized housing and have
a utility bill in your name, you may be eligible for assistance. A copy of the utility bill or documentation of responsibility
(example: copy of your rental agreement/lease or signed letter from your landlord) is required.
For a dwelling unit to be eligible for energy assistance benefits, its primary heat source must be:
• A regulated or unregulated utility (gas and electric)
• A permanent, free-standing fuel tank (oil and propane)
• A legal fireplace (wood)
• A legally vented wood/coal stove
Residents of any licensed medical facility (hospital, skilled nursing facility or intermediate care facility) or publicly operated
community residence (example: YMCA) are not eligible. Boarding/rooming houses, group homes or emergency shelters are
not eligible.
If eligible, the HEAP benefit amount will depend on federal funding levels, how many people live with you, total household
income and the main fuel used. In most cases, benefits are applied directly to the heating bill by the utility company. If you
are reverifying your PIPP amount, it will be based on either 10% or 5% of your total household income for the past 30 days,
depending on your heating source.
These are the programs you can apply for with this application:
• Home Energy Assistance Program (HEAP)
• Percentage of Income Payment Plan (PIPP)
• Home Weatherization Assistance Program (HWAP)
The State of Ohio is an Equal Opportunity Employer and Provider of ADA Services.
When determining 175% of the federal poverty guidelines, households with more than eight members must add $8,260 to the yearly income or
$678.90 to the 30-day income for each additional member. When determining 200% of the federal poverty guidelines, households with more
than eight members must add $9,440 for each additional member.
JULY 2022 – MAY 2023 Income Guidelines
Size of Household
1 $23,728.50 $27,180
2 $32,042.50 $36,620
3 $40,302.50 $46,060
4 $48,562.50 $55,500
5 $56,822.50 $64,940
6 $65,082.50 $74,380
7 $73,342.50 $83,820
8 $81,602.50 $93,260
(175%)
(For PI PP, E P P, H E AP,
WCP and SCP)
(200%)
(For HWAP)
How can I check the status of my application?
To check the status of your application, please visit energyhelp.ohio.gov and create an account.
Please note: HEAP benefits will be applied to your utility bill starting in January 2023.
If you have questions, please contact your local Energy Assistance Provider or send us a message by visiting
energyhelp.ohio.gov and clicking “contact us”.
Accepted Citizenship Documentation (DO NOT SEND ORIGINAL DOCUMENTS)
Proof of U.S. Citizenship Proof of Legal Resident/Qualified Alien
1. Birth Certificate/Hospital Birth Records
2. Baptismal Records
(Only when place and date of birth is
shown)
3. Indian Census Record
4. Military Service Record
5. U.S. Passport
6. Verified Citizenship for Ohio Works First
(OWF) Program
7. Voter Registration Cards
8. Social Security Cards
(Social Security Cards administered by
Social Security Administration that do not
include notes regarding work authorization
status will be accepted).
1. Naturalization Papers/Certifications of Citizenship
2. INS ID Card
3. Alien Registration Cards/Re-entry permits
4. INS Form I-151, IR1-9, or I-551 (Form I-151 will not be valid after
August 1, 1993)
5. INS Form I-94 if annotated with either: a) Sections 203(a)(7), 207,
208, 212(d)(5), 243(h), or 241(b)(3) of the Immigration and Nationality
Act: or b) One or a combination of the following terms: Refugee,
Parolee, or Asylee
6. Permanent Visa INS Form G-641, “Application for verification of
Information from INS Records”, when annotated at bottom by INS
representative as lawful admission for humanitarian reasons
7. Documentation that alien is classified pursuant to Sections: 101(a)(2),
203(a), 204(a)(1)(a), 207, 208, 212(d)(5), 241(b)(3), 243(h), or 244(a)(3), of
the Immigration and Nationality Act
8. Court order stating that deportation has been withheld pursuant to
Section 241(b)(3) or 243(h) or of the Immigration and Nationality Act
9. INS Form I-688
Accepted Proof of Income
Fixed
Income
Earned Employment
Income
Supplemental
Income
Other Sources of
Income
Other Earned
Income
Award/Benefit
letter
Payment printout/
statement from
issuing agency
Copy of check or
bank statement
including deposit
Most recent filed
IRS Form 1040 or
Tax Transcript
Most recent IRS
Form 1099
All pay stubs
received 30 days
from the date of
the application
that include gross
and year-to-date
amounts received
(including active
military pay).
Completed
and signed
Employment
Verification Form*
Copy of check/
award amount
letter
ODJFS documents/
eligibility letter
with amounts
and dates
Most recent IRS
Form 1099
Housing Authority
Documentation
Pay Stubs received
within the previous
30 days from
the date of the
application
Payment printout/
statement from
issuing agency
Statement
from Financial
Institution
Copy of check or
bank statement
showing deposit
Most recent IRS
Form 1099
Signed and
dated letter
from supporter
including name,
address, and
phone number
Pay stubs
indicating amount
received within
the previous 12
months from
the date of the
application
Self-Employment
Income and
Expense Form*
for the previous
12 months
Most recent filed
IRS Form 1040
and Schedules
Most recent IRS
Form 1099
Seasonal
Employment
Verification Form*
*All forms marked with an asterisk can be found at energyhelp.ohio.gov
Privacy Act Notice
DISCLOSURE: The disclosure of Social Security Numbers is mandatory to receive HEAP benefits.
AUTHORITY: 45 CFR 96.84 (c); 42 U.S.C. 405(c)(2)(C)(i)
USE: The state will use Social Security numbers in the administration of the Home Energy Assistance Program to verify
information supplied on the application to prevent, detect and correct fraud, waste, and abuse. The information is also used
to respond to requests for information from agency programs funded by block grants to states for Temporary Assistance for
Needy Families or agencies requesting information for child support or to establish paternity. The applicant may be held civilly
or criminally liable under federal or state law for knowingly making false or fraudulent statements.
Please tear here and keep instructions for your records
Primary Household Member Personal Information Section*
Enter the information completely. Do not send originals. PLEASE USE DARK BLUE OR BLACK INK.
Failure to fill out the application completely, provide all the required documentation and sign the
application (on the last page) will delay the processing of your application.
Please tear here and keep instructions for your records
First Name* M.I. Last Name*
Social Security Number*
U.S. Citizen / Legal Resident (Qualified Alien)
*
Military Status
Date of Birth (MM / DD / YYYY)*
Yes
No
Active
Veteran
No Military Service
Disabled* Gender
Ethnicity
Race
Non-Cash
Benefits
Number of Household
Members
Family Type Housing Type Residence Structure
Email Address Phone Number (including area code)
(
)
Preferred Method of Contact*
Mailing Address (number and street including route)*
Apt/Lot/Unit/Floor
City
* State* Zip Code* County*
Is Utility Service Address the Same?*
Current Service Address (if different from above; number and street including route) Apt/Lot/Unit/Floor
City State Zip Code County
Do You Receive Rental Assistance?
*
Landlord Organization (if you rent)
Landlord First Name
* Landlord Last Name*
Landlord Phone Number (including area code)
(
)
Landlord Mailing Address (number and street including route)*
Apt/Lot/Unit/Floor
City
* State* Zip Code* County*
Page 1 of 6
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Date Received
Client Number
American Indian/Alaskan Native
American Indian/Alaskan Native &
Black/African American
American Indian/Alaskan Native & White
Asian
Asian/White
Black/African American
Black/African American/White
Native Hawaiian/Other Pacific Islander
Other Multi-Race
White
Yes
No
Yes
No
Female
Male
Hispanic, Latino or Spanish Origins
Not Hispanic, Latino or Spanish Origins
Email
Postal
Same as above
Different (list below)
Single Parent/Male
Single Parent/Female
Two-Parent Household
Single Person
Own
Rent
Mobile Home
Single-Family
Multi-Family Low Rise (3 stories or less)
Multi-Family High Rise (4 stories or more)
Non-related Adults with Children
Multigenerational Household
Other
Supplemental Nutrition Assistance Program
(SNAP) / Food Stamps
Affordable Care Act Subsidy
Child Care Voucher
Housing Choice Voucher
HUD-VASH
Permanent Supportive Housing
Women, Infants, and Children (WIC)
Other
* Indicates required information in order to process your application.
For Office Use Only
Primary Household Member Income Section*
Failure to fill out the application completely, provide all the required documentation and sign
the application will delay the processing of your application.
Household Members and Income Section
If you have additional household members (anyone living under your roof at the same address), please complete Household
Members and Income Section of the application (this section), on pages 2–4. If you have more than 5 household members,
print an additional household member section page from energyhelp.ohio.gov or pick up another application at your Energy
Assistance Provider.
Page 2 of 6
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Fixed Income Earned Employment Income Supplemental Income Other Sources of Income
†
Other Earned Income
†
Social Security
Supplemental Security (SSI)
Social Security Disability
Insurance (SSDI)
Pension (Private and VA)
Widow/Widower’s Benefit
Alimony
Black Lung Pension
Wages
Active Military Pay
Unemployment
Utility Assistance
Workers’ Compensation
Employment Disability Payout
Strike Benefit
Cash withdrawn from IRAs /
Annuities / Other Investments
Interest Income
Lump Sum Payouts
(Estate and Trust Settlements /
Divorce Settlements / Insurance
Payout / Lottery Winnings)
Other
Self-employment
(includes owning own business,
babysitting, home party sales,
odd jobs, Ohio Electronic Child
Care, etc.)
Seasonal-employment
(includes teachers,
construction workers, etc.)
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Fixed Income Earned Employment Income Supplemental Income Other Sources of Income
†
Other Earned Income
†
Social Security
Supplemental Security (SSI)
Social Security Disability
Insurance (SSDI)
Pension (Private and VA)
Widow/Widower’s Benefit
Alimony
Black Lung Pension
Wages
Active Military Pay
Unemployment
Utility Assistance
Workers’ Compensation
Employment Disability Payout
Strike Benefit
Cash withdrawn from IRAs /
Annuities / Other Investments
Interest Income
Lump Sum Payouts
(Estate and Trust Settlements /
Divorce Settlements / Insurance
Payout / Lottery Winnings)
Other
Self-employment
(includes owning own business,
babysitting, home party sales,
odd jobs, Ohio Electronic Child
Care, etc.)
Seasonal-employment
(includes teachers,
construction workers, etc.)
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
†
These categories MUST provide
12 months of income documentation
†
These categories MUST provide
12 months of income documentation
Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*
Relationship to person applying
Disabled* Gender
Ethnicity
Race
U.S. Citizen / Legal Resident (Qualified Alien)
*
Yes
No
American Indian/Alaskan Native
American Indian/Alaskan Native &
Black/African American
American Indian/Alaskan Native & White
Asian
Asian/White
Black/African American
Black/African American/White
Native Hawaiian/
Other Pacific Islander
Other Multi-Race
White
Yes
No
Female
Male
Hispanic, Latino or Spanish Origins
Not Hispanic, Latino or Spanish Origins
Page 3 of 6 (OVER)
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Household Members and Income Section – Continued
Fill out the table below for all household members. Use additional section (on page 4) as needed for other household
members with income.
Fixed Income Earned Employment Income Supplemental Income Other Sources of Income
†
Other Earned Income
†
Social Security
Supplemental Security (SSI)
Social Security Disability
Insurance (SSDI)
Pension (Private and VA)
Widow/Widower’s Benefit
Alimony
Black Lung Pension
Wages
Active Military Pay
Unemployment
Utility Assistance
Workers’ Compensation
Employment Disability Payout
Strike Benefit
Cash withdrawn from IRAs /
Annuities / Other Investments
Interest Income
Lump Sum Payouts
(Estate and Trust Settlements /
Divorce Settlements / Insurance
Payout / Lottery Winnings)
Other
Self-employment
(includes owning own business,
babysitting, home party sales,
odd jobs, Ohio Electronic Child
Care, etc.)
Seasonal-employment
(includes teachers,
construction workers, etc.)
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Fixed Income Earned Employment Income Supplemental Income Other Sources of Income
†
Other Earned Income
†
Social Security
Supplemental Security (SSI)
Social Security Disability
Insurance (SSDI)
Pension (Private and VA)
Widow/Widower’s Benefit
Alimony
Black Lung Pension
Wages
Active Military Pay
Unemployment
Utility Assistance
Workers’ Compensation
Employment Disability Payout
Strike Benefit
Cash withdrawn from IRAs /
Annuities / Other Investments
Interest Income
Lump Sum Payouts
(Estate and Trust Settlements /
Divorce Settlements / Insurance
Payout / Lottery Winnings)
Other
Self-employment
(includes owning own business,
babysitting, home party sales,
odd jobs, Ohio Electronic Child
Care, etc.)
Seasonal-employment
(includes teachers,
construction workers, etc.)
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
†
These categories MUST provide
12 months of income documentation
†
These categories MUST provide
12 months of income documentation
Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*
Relationship to person applying
Disabled* Gender
Ethnicity
Race
U.S. Citizen / Legal Resident (Qualified Alien)
*
Yes
No
American Indian/Alaskan Native
American Indian/Alaskan Native &
Black/African American
American Indian/Alaskan Native & White
Asian
Asian/White
Black/African American
Black/African American/White
Native Hawaiian/
Other Pacific Islander
Other Multi-Race
White
Yes
No
Female
Male
Hispanic, Latino or Spanish Origins
Not Hispanic, Latino or Spanish Origins
Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*
Relationship to person applying
Disabled* Gender
Ethnicity
Race
U.S. Citizen / Legal Resident (Qualified Alien)
*
Yes
No
American Indian/Alaskan Native
American Indian/Alaskan Native &
Black/African American
American Indian/Alaskan Native & White
Asian
Asian/White
Black/African American
Black/African American/White
Native Hawaiian/
Other Pacific Islander
Other Multi-Race
White
Yes
No
Female
Male
Hispanic, Latino or Spanish Origins
Not Hispanic, Latino or Spanish Origins
Page 4 of 6
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Household Members and Income Section – Continued
Fill out the table below for additional household members.
Print additional pages, as needed, for other household members with income.
Fixed Income Earned Employment Income Supplemental Income Other Sources of Income
†
Other Earned Income
†
Social Security
Supplemental Security (SSI)
Social Security Disability
Insurance (SSDI)
Pension (Private and VA)
Widow/Widower’s Benefit
Alimony
Black Lung Pension
Wages
Active Military Pay
Unemployment
Utility Assistance
Workers’ Compensation
Employment Disability Payout
Strike Benefit
Cash withdrawn from IRAs /
Annuities / Other Investments
Interest Income
Lump Sum Payouts
(Estate and Trust Settlements /
Divorce Settlements / Insurance
Payout / Lottery Winnings)
Other
Self-employment
(includes owning own business,
babysitting, home party sales,
odd jobs, Ohio Electronic Child
Care, etc.)
Seasonal-employment
(includes teachers,
construction workers, etc.)
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
†
These categories MUST provide
12 months of income documentation
Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*
Relationship to person applying
Disabled* Gender
Ethnicity
Race
U.S. Citizen / Legal Resident (Qualified Alien)
*
Yes
No
American Indian/Alaskan Native
American Indian/Alaskan Native &
Black/African American
American Indian/Alaskan Native & White
Asian
Asian/White
Black/African American
Black/African American/White
Native Hawaiian/
Other Pacific Islander
Other Multi-Race
White
Yes
No
Female
Male
Hispanic, Latino or Spanish Origins
Not Hispanic, Latino or Spanish Origins
Fixed Income Earned Employment Income Supplemental Income Other Sources of Income
†
Other Earned Income
†
Social Security
Supplemental Security (SSI)
Social Security Disability
Insurance (SSDI)
Pension (Private and VA)
Widow/Widower’s Benefit
Alimony
Black Lung Pension
Wages
Active Military Pay
Unemployment
Utility Assistance
Workers’ Compensation
Employment Disability Payout
Strike Benefit
Cash withdrawn from IRAs /
Annuities / Other Investments
Interest Income
Lump Sum Payouts
(Estate and Trust Settlements /
Divorce Settlements / Insurance
Payout / Lottery Winnings)
Other
Self-employment
(includes owning own business,
babysitting, home party sales,
odd jobs, Ohio Electronic Child
Care, etc.)
Seasonal-employment
(includes teachers,
construction workers, etc.)
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 30 Days
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
Gross Income for the Past 12 Months
$
†
These categories MUST provide
12 months of income documentation
Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*
Relationship to person applying
Disabled* Gender
Ethnicity
Race
U.S. Citizen / Legal Resident (Qualified Alien)
*
Yes
No
American Indian/Alaskan Native
American Indian/Alaskan Native &
Black/African American
American Indian/Alaskan Native & White
Asian
Asian/White
Black/African American
Black/African American/White
Native Hawaiian/
Other Pacific Islander
Other Multi-Race
White
Yes
No
Female
Male
Hispanic, Latino or Spanish Origins
Not Hispanic, Latino or Spanish Origins
How do you heat your home?
Company/Vendor Account Number Costs included in rent? Shared Meter?
Account Holder’s First Name Account Holder’s Last Name Relationship to Primary Client
If you are currently enrolled in PIPP, do you wish
to reverify on this account?
Do you wish to enroll in PIPP and have a
regulated utility provider?
Page 5 of 6
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Total Household Eligible Income Section*
Please add the total income received for each adult household member then subtract the total household deductions.
Total Household Income
(add amounts from Household Income Section on pages 3 & 4)
Past 30 Days
$
Past 12 Months
$
Total Household Deductions
(from Household Deductions Section on page 5)
Past 30 Days
– $
Past 12 Months
– $
Total Eligible Income
Total Household Income minus Total Household Deductions above
$
Total Household Income minus Total Household Deductions above
$
If applicable, please explain the difference in the past 30 days income from the past 12 months income.
Please note: Income from child support received and VA disabilities are not countable income. For a complete list of excluded income,
please visit energyhelp.ohio.gov. Documentation of excluded income may be required to complete your application.
Utility Information Section*
Natural Gas
Propane or Bottle Gas (L.P. Gas)
Fuel Oil or Kerosene
Coal, Wood, or Pellets
Electric (Includes baseboards)
Other
Yes
No
Yes
No
Yes
No
Yes
No
Please provide your electric utility provider information (if not provided above):
Electric Company/Vendor Account Number Costs included in rent? Shared Meter?
Account Holder’s First Name Account Holder’s Last Name Relationship to Primary Client
If you are currently enrolled in PIPP, do you wish to reverify on this account?
Do you wish to enroll in PIPP and have a regulated utility provider?
Yes
No
Yes
No
Yes
No
Yes
No
Household Deductions Section*
Total Household Income Deductions (Choose all that apply)
Total Deductions for the past 30 Days
$
Total Deductions for the past 12 Months
$
Please note: Documentation of deduction(s) is required.
Attorney fees for estate or trust
settlements
Child Support paid-out
Health Insurance Premiums
Health Care Spending Accounts
Medicaid Spend Down (deductibles)
Medicare Premiums
Prescription Plans
Reimbursement for work expenses
Self-employment IRS allowable business
expenses
Short and long term disability
ENERGY ASSISTANCE PROGRAMS APPLICATION JULY 2022 – MAY 2023
Terms of Agreement
I agree To pay my Percentage of Income Payment Plan (PIPP) amount for my electric and/or natural gas service every month.
To go to my local Energy Assistance Provider or to energyhelp.ohio.gov to reapply at least once a year with updated
household information, and income documentation in order to remain eligible.
To contact my local Energy Assistance Provider or go online to energyhelp.ohio.gov to report any changes to my total
household income or number of household members, within 30 days of the change.
To accept any energy efficiency programs offered by Development or its designated providers, if eligible.
To allow my utility companies to release my name, address, telephone number, household member information, amount
of my utility usage, and total past due amount to Development and agencies that perform weatherization services
and/or provide other energy related services.
To allow Development to release my name, address, telephone number, household member information, and current
status to the utility companies, and other Energy Assistance Providers.
To allow Development to share my usage and demographic data with organizations contracted by Development to
evaluate the programs administered by Development.
I understand That I will not be re-verified if I owe any PIPP payments. I must make up these payments by the next billing cycle, or the
due date given to me by my utility companies.
That If I miss three or more consecutive payments, I will receive a notice on my bill and have one billing cycle after the
notice to make up payments or be dropped from PIPP.
That if I do not re-verify my income at least once every 12 months, I will be dropped from PIPP.
That if I do not make up missed PIPP payments by my stated Anniversary Date, I will be dropped from PIPP.
That the PIPP verification and anniversary dates are printed on the utility bills each month.
That if I make my PIPP payments in-full and on-time every month, I will receive a credit for 1/24th of my total past due
amount, and I will not need to pay the difference between my PIPP payment and my actual bill amount.
That if I reapply for PIPP and I am not eligible, or if I choose to be removed from PIPP, I can enroll in Graduate PIPP for up to
12 months after the date I am removed and still receive credits toward my past due amounts owed on my utility accounts.
That if I move out of the service area for my gas/electric company I can enroll in the Post PIPP program to make payments
on my closed account and receive credits toward the past due amounts.
That I am legally responsible for all past due amounts on my gas and/or electric accounts and if I am no longer enrolled
in PIPP, the past due amounts will become due. If these past due amounts are not paid in-full, the utility companies may
use any standard means of collection for the past due amounts on my accounts.
That I may appeal if my application is not decided upon within 12 weeks. I also may appeal within 30 days if I disagree
with my benefit amount or if I was denied assistance
General Authorization
An applicant who provides inaccurate income or household composition information risks: being dropped from PIPP and/or other energy assistance programs; being ineligible to reapply for 24 months;
having arrearage credits added back on to their utility bill; and/or receiving a bill from their utility (ies) for the full account balance.
I authorize the Tax Commissioner of the Ohio Department of Taxation or any agent or employee designated by the Tax Commissioner of the Ohio Department of Taxation as well as the Director of the Ohio
Department of Development or any designated agent or employee of the Director, or the Director of the Ohio Department of Jobs and Family Services or any designated agent or employee of the Director,
to disclose to the Director of the Ohio Department of Development or any designated agent or employee of the Director, or to the Tax Commissioner of the Ohio Department of Taxation, or any agent or
employee designated by the Tax Commissioner, all of my state of Ohio income tax information. The applicant expressly waives notice of the disclosure(s). The applicant expressly waives the confidentiality
provisions of the Ohio Revised Code which might otherwise prohibit disclosure and agrees to hold the Ohio Department of Taxation, the Ohio Department of Development, and the Ohio Department of
Jobs and Family Services, and their respective agents and employees harmless with respect to the disclosures herein. This authorization is to be liberally construed and interpreted; any ambiguity shall be
resolved in favor of the Tax Commissioner of the Ohio Department of Taxation, the Director of the Ohio Department of Development, and the Director of the Ohio Department of Jobs and Family Services.
I understand that by signing this application, I grant the Ohio Department of Development, or its authorized providers, access to my bank, employment, public assistance, utility company or other records
needed for verification and evaluation of services. I further grant Ohio Department of Development, or its authorized providers, access to any information that I have provided to any other state agency,
including but not limited to income information regarding requests for public assistance. I understand that filling out this application does not guarantee that my household will receive assistance. If I am
or become a PIPP customer I understand that I may be included in a group for which electric service is purchased in common. I understand that any authorized provider may rescind an approved payment
if information is acquired which determines that my household is not eligible for services according to the rules of each program. I understand that I have the right to appeal. I certify that the information
I have provided in this application is, to the best of my knowledge, a true, accurate and complete disclosure of the requested information. I understand that I may be held civilly and criminally liable under
federal and state laws for knowingly making false or fraudulent statements.
I declare under penalty of perjury that the information submitted in this application is true and correct.
X Sign Here
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Application Date
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
PLEASE SIGN AND MAIL APPLICATION TO:
Office of Community Assistance, Home Energy Assistance Program
P.O. Box 1240, Columbus, Ohio 43216
Date Printed – August 2022
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