1. Healthcare

CONSUMERS AFFORDABLE
RESOURCE FOR ENERGY
(CARE) PROGRAM
Bringing energy affordability
to Michigan
Welcome! We’re happy you’re interested in applying for the Consumers Affordable Resource for Energy or CARE
Program. Through this program, Consumers Energy is helping qualified customers afford and better manage their
monthly energy costs.
Customers in the CARE Program can receive many benefits, including:
(1) 40% off your monthly energy charges;
(2) Forgiveness of any past-due balance;
(3) Learning how to be more energy-efficient at home, and;
(4) The chance for an energy expert to visit your home, free of charge, and install items
to save even more through the Helping Neighbors Program.
If your account is past due and your household income meets the guidelines shown
here, we invite you to apply:
(1) Fill out the forms in this application packet and gather the supporting
documentation. It’s divided into three sections:
I. Information about you
II. Information about other people living in your household
III. Information about your total household income and expenses
You must complete all three sections, sign page 6, and return the application with your
attached documentation.
(2) Submit the application by mail, fax or email*:
x
x
x
Mail to: CARE Program, P.O. Box 26067, Lansing, MI 48909-9883
Fax to: (877) 443-3918
Email: [email protected]
If you have questions or concerns about mail, fax or email, call (877) 448-9433.
*Understand that neither the Consumers Energy call center nor 2-1-1 can enroll you into CARE. An application is required,
and Consumers Energy is partnering with human service agencies to determine eligibility for the program.
Space in the CARE Program is limited, and spots will fill quickly. We cannot guarantee enrollment once the program is
full. If you intend to apply, we encourage you to respond soon by following the instructions above.
Sincerely,
CARE Program Team
Consumers Energy
CONSUMERS ENERGY CARE PROGRAM
P.O. Box 26067, Lansing, MI 48909-9883
ConsumersEnergy.com/assistance
CONSUMERS ENERGY
CARE 2.0 PROGRAM
ENROLLMENT APPLICATION
APPLICATION CHECKLIST
o
Must be 18 years or older to apply
o Must be a U.S. citizen or legal alien to apply
o Must have a Consumers Energy balance that is past due
o The Consumers Energy account must be in your or your spouse’s name
PLEASE INCLUDE
PHOTOCOPIES OF
ALL DOCUMENTS
AND DO NOT SUBMIT
ANY ORIGINAL
DOCUMENTS
o All three application sections completed, signed and dated
(must sign bottom of page 6)
o
Copy of most recent Consumers Energy bill
o
Copies of Identification documents for primary applicant only:
(1) A copy of Social Security Card
AND
(2) A copy of ONE other form of government-issued photo ID (e.g., driver’s license, state ID, passport or
U.S. Military ID)
o Copies of entire Household’s Income and Expense documents: See instructions - “Acceptable
Forms of Household Income Documents” (page 2)
o
EASE survey at the end of this packet
Please understand that providing incomplete information within your submitted application packet will
delay processing.
1014
HELPING MICHIGAN SAVE ENERGY. THAT’S OUR PROMISE.
ACCEPTABLE FORMS OF HOUSEHOLD INCOME DOCUMENTS
(Must include income for every person in your household.)
1. WAGES FROM EMPLOYMENT OR BUSINESS (For every wage earner in your household):
• Paystubs (from last 60 days): If paid weekly, provide four paystubs covering one full month. If paid bi-weekly, provide two
paystubs for one full month. If paid monthly, provide one paystub for one full month.
OR
• Print off or letter from employer (from last 60 days): Must cover one full month of pay with worker's name, on company
letterhead and signed by an authorized supervisor.
2. OTHER BENEFITS OR UNEARNED INCOME (Submit copies of any that apply to your household): All documents must be dated within
the last 60 days. If older than 60 days, also send copy of the bank statement showing the most recent deposit within the last 60
days. For your own security, cross out the bank account number.
• SSI, Social Security, RSDI, SSDI, SDA and/or pension: Submit a 2014 or 2015 award letter.
• Child Support: Submit copy of the Office of Child Support report or a printed summary from the Court showing the gross
amount received within a full 30-day period.
• DHS FIP Cash Assistance: Submit copy of the benefit letter or MI Bridges statement dated within the last 60 days.
• Workers Compensation: Submit the most recent workers compensation award letter.
• Unemployment: Submit the most current unemployment award letter or a printout from MARVIN/LARA website showing the
gross amount received.
• Adoption Subsidy/Direct Care through the State of Michigan: Submit the most recent pay stubs, remittance advice statement, or
State of Michigan award letter.
• Alimony or Spousal Support: Submit the divorce agreement and bank statements or interest, annuities or dividend statements.
• Other: Provide any other unearned income documentation for the most current 30-day pay period.
3. SELF-EMPLOYMENT: Complete the attached self-employment affidavit (page 7 of this packet) and provide the following documents:
• Federal or state tax forms
AND
• Self-employment profit and loss statement
4. NO INCOME: If no one in your household received any income in the past 60 days, please complete and sign the zero-income affidavit
(page 8 of this packet).
Consumers Energy CARE 2.0 Program Enrollment Application l 2 of 8
REQUIRED INFORMATION
Section I: INFORMATION ABOUT THE PRIMARY ACCOUNT HOLDER (Copies of IDs required)
NAME OF CONSUMERS ENERGY ACCOUNT HOLDER (FIRST NAME, MIDDLE INITIAL, LAST NAME)
SOCIAL SECURITY NUMBER (000-00-000)
DATE OF BIRTH (MM/DD/YY)
ACCOUNT FUEL TYPE:
o Electric
o Gas
o Combination
CONSUMERS ENERGY ACCOUNT NUMBER
SERVICE ADDRESS
CITY
COUNTY
STATE
ZIP
MAILING ADDRESS (IF DIFFERENT FROM ABOVE)
CITY
COUNTY
STATE
ZIP
PRIMARY PHONE NUMBER
SECONDARY PHONE NUMBER
o Morning
o Morning
o WEEKDAY:
o WEEKEND:
BEST CONTACT TIME:
Cell phone
o
Permission to text updates
o
Cell phone
o
Permission to text updates
o Evening
o Evening
GENDER
o M
o
ARE YOU DISABLED?
o Yes
o No
MI
o
o Afternoon
o Afternoon
EMAIL ADDRESS
MI
F
ARE YOU A VETERAN?
o Yes
o No
CITIZENSHIP STATUS
o U.S. citizen
o Legal alien
IS ANY HOUSEHOLD MEMBER
CURRENTLY PREGNANT?
o Yes
o No
INTAKE QUESTIONNAIRE
Is the Consumers Energy account in your and/or your spouse’s name?
o Yes
o
No
Have you received State Emergency Relief (SER) for this Consumers Energy utility account from the Department of
Human Services since October 1, 2014? Receiving SER will not disqualify you from CARE re-enrollment.
o
Yes
o
No
Have you received utility assistance from any agency in the past 12 months?
o
Yes
o
No
Do you own or rent your home?
o
Own
o
Rent
REASON FOR ENERGY ASSISTANCE
o Limited-income household
o
Job loss
Av
o
Medical hardship
o
Other (explain):
How did you first learn about the CARE Program?
o
Friend or Family
o
Consumers Energy letter
o
2-1-1
o
Newspaper or magazine
o
Website
o
Consumers Energy call center
o
Another agency
o
o
Consumers Energy payment office
o
TV
o
Radio
Other_______________________________________
Consumers Energy CARE 2.0 Program Enrollment Application l 3 of 8
Section II: OTHER PEOPLE IN YOUR HOUSEHOLD (Copies of IDs NOT required)
Customer to complete table. Total number of members, including the applicant, in the household:
RELATIONSHIP
TO APPLICANT
SSN
NAME (FIRST NAME, MIDDLE INITIAL, LAST NAME)
(000-00-000)
DATE OF
BIRTH (mm/dd/yy)
CHECK ALL
THAT APPLIES
/
/
o
o
Disability
Veteran
/
/
o
o
Disability
Veteran
/
/
o
o
Disability
Veteran
/
/
o
o
Disability
Veteran
/
/
o
o
Disability
Veteran
/
/
o
o
Disability
Veteran
/
/
o
o
Disability
Veteran
/
/
o
o
Disability
Veteran
/
/
o
o
Disability
Veteran
/
/
o
o
Disability
Veteran
If you have more than 10 household members, please attach their information to this application.
Section III: INFORMATION ABOUT YOUR HOUSEHOLD INCOME AND EXPENSES
Do any of the household members receive income? o Yes
o No
If no one in your household receives income, you must complete the zero-income affidavit (page 8) and return it with your application.
Of the household members who are employed, are any self-employed? o Yes
o No
If yes, each self-employed member must complete the self-employed affidavit (page 7) and return it with your application.
WAGES OR BUSINESS INCOME
Are you or another household member employed? o Yes
o No
If yes, it is necessary to complete the income validation table below, include proof of income (see instructions, page 2), and return copies
with your application.
FIRST & LAST NAME
EMPLOYER’S NAME
START DATE
END DATE
(IF APPLICABLE)
GROSS EARNINGS
PAY FREQUENCY
$
o
o
o
o
Weekly
Every other week
Monthly
Temp or annual salary
$
o
o
o
o
Weekly
Every other week
Monthly
Temp or annual salary
$
o
o
o
o
Weekly
Every other week
Monthly
Temp or annual salary
$
o
o
o
o
Weekly
Every other week
Monthly
Temp or annual salary
(BEFORE TAXES)
Consumers Energy CARE 2.0 Program Enrollment Application l 4 of 8
INCOME FROM BENEFITS OR OTHER SOURCES
INCOME SOURCE
NUMBERS
Does anyone in your household receive any NON-WAGE income? o Yes
o No
If yes, complete the table below, include proof of this income (see instructions, page 2), and return it with your application.
1.
2.
3.
4.
5.
Social Security benefits
Pension/retirement benefits
Veteran’s benefits
Military allotments
DHS FIP cash assistance
FIRST & LAST NAME
6.
7.
8.
9.
10.
Supplemental Security Income (SSI)
Worker’s compensation
Child support (received)
Tribal payments
Adoption subsidy
INCOME SOURCE NUMBER
11.
12.
13.
14.
Disability benefits
Unemployment compensation
Rental income
Other:
PAY FREQUENCY
(FROM TABLE ABOVE)
AMOUNT RECEIVED
o
o
o
o
Weekly
Every other week
Monthly
Temp or annual salary
$
o
o
o
o
Weekly
Every other week
Monthly
Temp or annual salary
$
o
o
o
o
Weekly
Every other week
Monthly
Temp or annual salary
$
o
o
o
o
Weekly
Every other week
Monthly
Temp or annual salary
$
o
o
o
o
Weekly
Every other week
Monthly
Temp or annual salary
$
o
o
o
o
Weekly
Every other week
Monthly
Temp or annual salary
$
o
o
o
o
Weekly
Every other week
Monthly
Temp or annual salary
$
HOUSEHOLD EXPENSES NOT COUNTED IN INCOME
Does anyone in your household pay any of the following expenses? o
Yes
o
No
If yes, complete the table below, include proof of these expenses, and return copies with your application.
FIRST & LAST NAME
EXPENSE
MONTHLY AMOUNT SPENT
o
o
o
Health insurance premiums
Court-ordered child support (paid)
Out-of-pocket childcare costs (limited)
$
o
o
o
Health insurance premiums
Court-ordered child support (paid)
Out-of-pocket childcare costs (limited)
$
o
o
o
Health insurance premiums
Court-ordered child support (paid)
Out-of-pocket childcare costs (limited)
$
o
o
o
Health insurance premiums
Court-ordered child support (paid)
Out-of-pocket childcare costs (limited)
$
o
o
o
Health insurance premiums
Court-ordered child support (paid)
Out-of-pocket childcare costs (limited)
$
Consumers Energy CARE 2.0 Program Enrollment Application l 5 of 8
PROGRAM TERMS, CONDITIONS & RELEASE OF INFORMATION
I affirm that this information is true and complete, that it is subject to verification, and if found fraudulent, I will not be
eligible for the energy assistance from the CARE Program.
I understand that Consumers Energy does not guarantee enrollment in this program.
I also agree to the following program terms and conditions in order to qualify for the CARE Program:
1. The Consumers Energy bill is in my name or my spouse’s name, and I must live at the address where the discount
will be received.
2. I am not claimed as a dependent on another person’s income tax return other than my spouse.
3. I do not share an energy meter with another home.
4. I will renew my eligibility annually and/or notify Consumers Energy if my household is no longer eligible for the CARE
discount.
5. I understand as part of the enrollment process I may be required to provide proof of qualifying household income for
all occupants which, in some cases, may require providing IRS Tax Return Transcripts, recent check stub (dated no
later than 60 days from my CARE application date), Wages (W-2); unemployment statements/letters; social security
statements/letters; pension statements/letters; workman’s compensation statements/letters; alimony or spousal
support statements/letters; disability statements/letters; interest, annuities, or dividends statements/letters; rental
income receipts, DHS FIP payments.
6. I understand if any of the information provided above is found to be untrue, any CARE Program benefits may
be withdrawn.
7. I will allow Consumers Energy to share my information with collaborating non-profits, state and federal agencies, for
the sole purpose of facilitating CARE enrollment and participation.
8. As a condition of CARE enrollment I consent to being contacted by 2-1-1 of Michigan for future opportunities
related to free tax preparation services and as needed by the CARE application processing vendor that may include
communication via text messaging.
SIGNATURE:
DATE:
Consumers Energy CARE 2.0 Program Enrollment Application l 6 of 8
SELF-EMPLOYMENT AFFIDAVIT
This affidavit is to be signed by any individual who is 18 years of age and over in the applicant’s household 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 (MM/DD/YY):
/
/
• To the best of my knowledge, I expect to earn $_______________ in the upcoming 12 months.
• Return a copy of a recent 1040 & 1040 Schedule C form and a full 60 days of business information from one of the
following options:
o
Bank Statements
o
Accountant’s/bookkeeper’s statement
o
Business receipts/check stubs
o
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:
Consumers Energy CARE 2.0 Program Enrollment Application l 7 of 8
ZERO HOUSEHOLD INCOME AFFIDAVIT
• Applicant name:
• Address:
I hereby certify that no person in my household receives income from any of the following sources:
• Wages from employment (including tips, commissions, bonuses, fees, etc.)
• Income from operation of a business
• Rental income from real or personal property
• Social security payments, pensions, annuities, retirement funds, insurance policies or death benefits
• Unemployment or disability payments
• Public assistance payments
• Periodic allowances such as alimony, child support or gifts received
• Sales from self-employment
• Any other source not named above
SIGNATURE:
DATE:
Consumers Energy CARE 2.0 Program Enrollment Application l 8 of 8
EASE
SURVEY
Welcome to the Everyday Actions Save Energy
(EASE) Survey. This short 9-question survey will
scratch-the-surface of your home’s energy use
and provide you with a personalized home energy
profile. Your home’s energy profile is based on
your answers and will help you keep your home
comfortable and efficient.
FULL NAME
Please answer all questions. If you’re unsure, we ask that you make your best guess.
TELL US ABOUT YOUR HOME
1. What is the location of your home?
Address:
City:State:ZIP:
2. How big is your home?
o Small House (500-1600 Sqft.)
o Medium House (1600-3500 Sqft.)
o Large House (3500-8000 Sqft.)
3. How many people live in your home?
Number of residents:
4. How much insulation do you have?
o Don’t Know
o Some Insulation
o Thick Insulation
o No Insulation
5. What type of heating and cooling system is in your home?
o Electric Heat w/Central Air
o Propane w/Central Air
o Electric Heat w/o Central Air
o Propane w/o Central Air
o Gas Furnace/Boiler w/Central Air
o Heat Pump
o Gas Furnace/Boiler w/o Central Air
o High Eff. Heat Pump
o High Eff. Gas Furnace/Boiler w/Central Air
o Other:
o High Eff. Gas Furnace/Boiler w/o Central Air
6. What are your average temperature settings?
Heat:
Air:
Consumers Energy EASE Survey l 2 of 3
7. What type of water heater is in your home?
o Electric Water Heater
o Gas Tankless
o Electric High Efficiency
o Propane
o Gas Water Heater
o Propane High Efficiency
o Gas High Efficiency
o Heat Pump
Electric water heater is plugged into an outlet
Natural gas or propane water heater is vented
8. How many refrigerators and freezers do you have in your home?
Number of Refrigerators:
Number of Freezers:
9. What type of lighting do you have?
o Few High Efficiency
o Mix of High Efficiency and Conventional
o Mostly High Efficiency
Thank you for completing the EASE survey.
Consumers Energy EASE Survey l 3 of 3