1. No category

Dear Valued Customer:
Eversource is offering free weatherization services designed to lower your energy bill.
The HES-IE program is available to renters or homeowners with a GROSS income at or
below 60 percent of the state median income. You may receive energy-saving compact
fluorescent lightbulbs (CFLs), caulking, weather stripping and much more.
Please complete all pages and return to us via mail. Our address: Home Energy
Solutions – Income Eligible, Eversource, P.O. Box 270, Hartford, CT 06101-9902.
Remember, if you rent, your landlord must complete the Owners Permission Statement.
Your verification of income must be submitted along with the application. Also, please
be sure to check each box on the form so your application can be processed without
delay.
Sincerely,
The Energy Efficiency Team
Eversource
Respetable Cliente:
La compañia Eversource esta ofreciendo servicios gratis de aclimatacion diseñados
para ayudarle a reducer sus cuentas de energia. El Programa HES-IE esta disponible
para inquilinos ó dueños con ingresos brutos al 60 porciento ó menos del promedio de
ingresos del estado. Puede recibir bombillas fluorescente que ahorran energia,
calafatee, burlete y mucho mas.
Complete por favor todas las paginas y envielas a nuestro correo postal: Home Energy
Solutions – Income Eligible, Eversource, P.O. Box 270, Hartford, CT 06101-9902.
Recuerde, si usted alquila, su propietario tiene que completer la Declaracion de Permiso
de Propietarios. Su verificacion de ingreso debe ser sometido juntamente con la
solicitud. Tambien asegure de reviser cada seccion de la solicitud para que sea
procesada sin demoras.
Sinceramente,
The Energy Efficiency Team
Eversource
Owner’s Permission Statement
Free HES-IE Weatherization Services
I am the owner or authorized agent of the residential building(s) located at:
I hereby give permission to Eversource and Connecticut Natural Gas (CNG), or
their authorized agents, to perform an energy conservation needs assessment
and to install energy conservation measures at the above referenced location
at no cost to me.
Owner/Agent
Address
City, State, Zip
Telephone
Signature
Print Name
Date
E-mail
Authorized agents include the utility administrator, Community Action Agency
weatherization department, or contractor hired to install conservation
measures.
Please return this form in the postage-paid envelope enclosed with the
application or mail to:
HES-IE Weatherization Services
Eversource
PO Box 270
Hartford, CT 06101-9902
HES IE Income Verification Statement
Thank you for your interest in the HES IE Weatherization Service program. Before your application
can be processed you will need to return this form with verification of your income.
The following are valid forms of verification:
* Copy of last four current paystubs
* Work wages
*Pension / Retirement
* Proof of rental income if applicable
* Proof of Unemployment
* Proof of Social Security / Disability
* Proof of State Assistance
Be sure to return your income verification with the application.
Energize Connecticut helps you save money and use clean energy. It is an initiative of the Energy Efficiency
Fund, the Connecticut Green Bank, the State, and your local electric and gas utilities with funding from a
charge on customer energy bills.
Application for FREE HES-IE Services
READ AND COMPLETE ENTIRE FORM
NAME / NOMBRE
ADDRESS / DIRECCION
CITY / CIUDAD
STATE / ESTADO
TELEPHONE NUMBER / NUMERO DE TELEFONO
EMAIL / CORREO ELECTRONICO
ZIP CODE / CODIGO POSTAL
BEST TIME TO CALL / MEJOR HORA PARA LLAMAR
MORNING
HOME TOTAL SQ. FT / TOTAL EN PIES CUADRADOS
AFTERNOON
EVENING
TOTAL HEATED SQ. FT. / PIES CUADRADO CON CALEFACCION
PLEASE COMPLETE ALL THAT APPLY:
EVERSOURCE ELECTRIC ACCOUNT NO.
EVERSOURCE GAS ACCOUNT NO.
OIL COMP. NAME & ACCOUNT NO.
CNG ACCOUNT NO.
SCG ACCOUNT NO.
PLEASE ANSWER ALL QUESTIONS BELOW. ALL INFORMATION IS STRICTLY CONFIDENTIAL.
1.
I am a / Soy:
Homeowner / Dueño
Tenant / Inquilino
7.
My heating source is: (check only one)
Oil
If you rent, you must print your landlord’s / agent’s name and
address below. LANDLORD / AGENT MUST SIGN ATTACHED
PERMISSION STATEMENT.
Electric
Gas
Propane
NAME
Solar
ADDRESS
8.
CITY
STATE
ZIP CODE
My water is heated by: (check only one)
Oil
Electric
2.
Household information / Informacion de Casa:
Gas
Propane
Total # of people in household:
Solar
Num. of children / niños:
9.
Num. of elderly / anciano:
Num. of disabled / incapacitado:
3.
My heating system type: (check only one)
Hydro Air
Furnace
The total GROSS monthly income of all members in my household:
Ingreso Total Mensual
Baseboard / Radiant
$
Geothermal
Heat Pump
You are required to provide documentation to substantiate
your income. Documentation may include pay stubs, social
security check receipts and pension slips. Eversource reserves
the right to verify income before services are provided.
Boiler
10. My cooling system type: (check only one)
Central AC
4.
My source of income is from: (check all that apply)
Wages / Sueldo
5.
PTAC
State Assistance
Window AC
Social Security / SSI
None
Received State Energy Assistance (provide copy of award letter):
Recibio Asistencia de Energia Estatal (incluya copia de la carta)
Yes
6.
Heat Pump
Other
No
I live in a: (check one only)
Single Family
2-4 Units
Townhouse / Rowhouse
5 + Units
Mobile Home
Condo
For Office Use Only
WO# / Date / Initials:
CR6338-1 REV. 2-15
I understand there will be no cost to me or my landlord / agent
to receive these free weatherization services. I authorize
my gas / oil company to release usage information to Eversource
and its agents. I affirm that the information in this form is accurate.
I understand that if the information is not correct, I may be
charged for the conservation assistance I am provided by the
HES-IE program.
Please sign below:
Signature / Firma:
Date / Fecha:
Affidavit of Household With No Income
Home Energy Solutions - Income Eligible Program (HES-IE)
I,
, affirm that no one over the age of 18 years who lives in
my household, has had any income in the four weeks before the date I signed this affidavit. This means
no adult in my household has received income from work, a pension, unemployment or worker's
compensation, cash assistance from the Connecticut Department of Social Services (Temporary Family
Assistance, State Supplement or the State Administered General Assistance program), benefits from the
Social Security or Veteran's Administration, child support, interest, or any other income source.
The following people live in my household:
Name
Check if person is under 18 years old
I understand that the HES-IE program may request documentation regarding my income.
I affirm that the information in this form is accurate. I understand that if the information is not correct, I
may be charged for the conservation assistance I am provided by the HES-IE program.
Name:
Date:
Phone Number:
Energize Connecticut – programs funded by a charge on customer energy bills
9385 3-15
Declaración Jurada de Familia Sin Ingresos
Soluciones de Energía Para El Hogar - Programa de Ingresos Elegibles (HES-IE)
Yo, _______________________________________ afirmo que nadie sobre la edad de 18 años que
vive en mi casa, ha tenido algún ingreso en las cuatro semanas antes de la fecha firmada en esta
declaración jurada. Esto significa que ningún adulto en mi hogar ha recibido ingresos de trabajo,
una pensión, desempleo o compensación del trabajador, asistencia en efectivo del Departamento
de Servicios Sociales de Connecticut (asistencia de familia temporal, suplemento estatal o el
programa estatal de asistencia general), beneficios del Seguro Social o de veteranos,
manutención, interés o cualquier otra fuente de ingresos.
Las siguientes personas viven en mi casa:
Nombre
Verifique si la persona es menor de 18 años de edad
Yo entiendo que el programa HES-IE puede solicitar documentación sobre mis ingresos.
Afirmo que la información contenida en este formulario es correcta. Entiendo que si la
información no es correcta, me pueden cobrar la asistencia de conservación recibida por el
programa de HES-IE.
Nombre:
La fecha:
Teléfono:
Energize Connecticut – programs funded by a charge on customer energy bills