1. Healthcare

CONSUMERS AFFORDABLE
RESOURCE
FOR
ENERGY
CONSUMERS
AFFORDABLE
CONSUMERS
AFFORDABLE
CONSUMERS
AFFORDABLE
(CARE)
PROGRAM
RESOURCE
FOR
ENERGY
RESOURCE
FOR
RESOURCE
FORENERGY
ENERGY
(CARE)
PROGRAM
Bringing
energy
affordability
CONSUMERS
AFFORDABLE
CONSUMERS
AFFORDABLE
(CARE)
PROGRAM
(CARE)
PROGRAM
to Michigan
RESOURCE
FOR
ENERGY
RESOURCE
ENERGY
Bringing
energyFOR
affordability
Bringing
energy
affordability
Bringing
energy
affordability
to
Michigan
(CARE)
PROGRAM
(CARE)
PROGRAM
toWelcome!
Michigan
to Michigan
We’re
happy
you’re
interested
in applying for the Consumers Affordable Resource
Bringing
energy
affordability
Bringing
energy
affordability
Welcome!
for
Energy
or
CARE
program.
Through
this program, Consumers Energy is helping
Welcome!
toWelcome!
Michigan
to Michigan
qualified
customers afford and better manage their monthly energy costs. CARE
We’re happy you’re interested in applying for the Consumers Affordable Resource
customers
receive
assistance
with
a past-due
balance,
monthly
bill credits,
and
for
Energy
or
CARE
program.
Through
this for
program,
Consumers
Energy
isResource
helping
We’re
happy
you’re
interested
ininapplying
Affordable
We’re
happy
you’re
interested
applying
forthe
theConsumers
Consumers
Affordable
Resource
energy-efficiency
tools
to
save
even
more.
qualified
customers
afford
and
better
manage
their
monthly
energy
costs.
CARE
for
forEnergy
EnergyororCARE
CAREprogram.
program.Through
Throughthis
thisprogram,
program,Consumers
ConsumersEnergy
Energyisishelping
helping
Welcome!
Welcome!
customers
receive assistance
with
a past-due
balance,
monthly
bill credits,
and
qualified
customers
afford
and
better
manage
their
monthly
energy
costs.
CARE
qualified
customers
afford
and
better
manage
their
monthly
energy
costs.
CARE
If
your
household
income
meets
the
guidelines
shown
here,
there
are
two
steps:
energy-efficiency
tools
to
save
even
more.
customers
receive
assistance
with
aapast-due
balance,
monthly
bill
credits,
and
customers
receive
assistance
with
past-due
balance,
monthly
bill
credits,
and
We’re
happy
you’re
interested
in
applying
for
the
Consumers
Affordable
Resource
We’re
happy
you’re
interested
in
applying
for
the
Consumers
Affordable
Resource
energy-efficiency
tools
totosave
even
more.
energy-efficiency
tools
save
even
more.
(1)
Fill
out
theCARE
forms
in this
application
andConsumers
gather
the
supporting
Energy
or
program.
Through
thispacket
program,
Energy
is
helping
for Energy
or
CARE
program.
Through
thisguidelines
program,
Consumers
Energy
isare
helping
Iffor
your
household
income
meets
the
shown
here,
there
two
steps:
documentation.
The
packet
contains
a
checklist
that
will
help
you
prepare
a
qualified
customers
afford
and
better
manage
their
monthly
energy
costs.
CARE
qualified
customers
afford
and
better
manage
their
monthly
energy
costs.
CARE
IfIfyour
household
income
meets
the
guidelines
shown
here,
there
are
your
household
income
meets
the
guidelines
shown
here,
there
aretwo
twosteps:
steps:
complete
application.
Incomplete
applications
will
take
longer
tocredits,
process.
customers
receive
assistance
with
a past-due
balance,
monthly
bill
customers
receive
assistance
with
a past-due
balance,
monthly
bill
and and
(1)
Fill
out the
forms
in this
application
packet
and
gather
thecredits,
supporting
energy-efficiency
tothis
save
more.
energy-efficiency
toolstools
toThe
save
eveneven
more.
packet
contains
apacket
checklist
that
will the
help
you
prepare a
(1)
Fill
inin
packet
and
gather
(1) documentation.
Fillout
outthe
theaforms
forms
thisapplication
application
and
gather
thesupporting
supporting
(2)
Dial
2-1-1,
toll-free
service
of
the
United
Way.
Tell
the
representative
you aare
complete
application.
Incomplete
applications
will
take
longer
to
process.
documentation.
The
contains
aachecklist
that
will
you
prepare
documentation.
Thepacket
packet
contains
checklist
thathere,
willhelp
help
you
prepare
a
calling
about
the
“Consumers
Energy
CARE
Program,”
and
they
will
direct
you
:
If
your
household
income
meets
the
guidelines
shown
there
are
two
steps:
If your household
income meets
the guidelines
shown
here,
there
are
steps:
complete
application.
Incomplete
applications
will
take
longer
tototwo
process.
complete
application.
Incomplete
applications
will
take
longer
process.
to the2-1-1,
nearest
enrollment
location
willTell
submit
the application.
(2) Dial
a toll-free
service
of thewhere
Unitedyou
Way.
the representative
you are
(1)
Fill
out
the
forms
in
this
application
packet
and
gather
the
supporting
(1) (2)
Fill calling
out
the
forms
in
this
application
packet
and
gather
the
supporting
about
the
“Consumers
Energy
CARE
Program,”
and
they
will
direct
you
service
ofofthe
Way.
Tell
the
representative
you
are
(2) Dial
Dial2-1-1,
2-1-1,aatoll-free
toll-free
service
theUnited
United
Way.
Tell
the
representative
you
For
your
convenience,
you
may
instead
submit
your
completed
application
byaare
mail, fax or email. See the contact
documentation.
The
packet
contains
a
checklist
that
will
help
you
prepare
documentation.
The
packet
contains
a
checklist
that
will
help
you
prepare
a
to
the
nearest
enrollment
location
where
you
will
submit
the
application.
calling
about
the
“Consumers
Energy
CARE
Program,”
and
they
will
direct
you
calling
about
the
“Consumers
Energy
CARE
Program,”
and
they
will
direct
you
information
below.
Customers
who
apply
by
mail
will
receive
notification
from
the
CARE
Program within 30 days.
complete
application.
Incomplete
applications
will
take
longer
to
process.
complete
application.
Incomplete applications
will take
longer toapplication.
process.
totothe
thenearest
nearestenrollment
enrollmentlocation
locationwhere
whereyou
youwill
willsubmit
submitthe
the application.
For your convenience, you may instead submit your completed application by mail, fax or email. See the contact
If
you2-1-1,
qualify
to
enroll
inyou
the
CARE
andWay.
stay
current
on your
payments,
you
willfax
receive within
a 40%
credit
on your
(2)
Dial
2-1-1,
a toll-free
service
ofprogram,
the United
Tell
the notification
representative
you
are
(2) For
Dial
abelow.
toll-free
service
ofwho
the
United
Way.
Tell
the
representative
you
are
information
Customers
apply
by
mail
will
receive
from
the
CARE
30
days.
convenience,
may
instead
submit
your
completed
application
byby
mail,
See
the
Foryour
yourenergy
convenience,
you
may
instead
submit
your
completed
application
mail,Program
faxororemail.
email.
See
thecontact
contact
monthly
charges
through
September
2015,
plus
forgiveness
of
your
past
due
balance
(30%
at
enrollment
+
calling
about
the
“Consumers
Energy
CARE
Program,”
and
they
will
direct
you
calling aboutbelow.
the “Consumers
Energy
CARE
and they
will directfrom
you the CARE Program within 30 days.
information
Customers
who
apply
bybyProgram,”
mail
will
receive
notification
information
below.
Customers
who
apply
mail
will
receive
notification
from
the
CARE
Program
within
30
days.
the
remainder
throughout
the
program
year).
You
will
also
receive
offers
to
help
make
your
home
more
energy
to
the
nearest
enrollment
location
where
you
will
submit
the
application.
thequalify
nearesttoenrollment
location
youand
will stay
submit
the application.
Iftoyou
enroll in the
CARE where
program,
current
on your payments, you will receive a 40% credit on your
efficient!
monthly
energy
charges
through
September
2015,
plus
forgiveness
of
your pastyou
due
balance
atcredit
enrollment
+
If
you
qualify
to
enroll
in
the
CARE
program,
and
stay
current
on
payments,
will
receive(30%
aa40%
on
If you
qualify
to enroll inyou
themay
CARE
program,
and stay
current
onyour
your
payments,
you
will
40%
credit
onyour
your
For
your
convenience,
instead
submit
your
completed
application
byhelp
mail,
faxreceive
or
email.
See
the energy
contact
For monthly
your
convenience,
you may
instead
submit
your
completed
application
by past
mail,
faxmake
or
email.
See
theenrollment
contact
the
remainder
throughout
the
program
year).
You
will
also
receive
offers
to
your
home
more
energy
charges
through
September
2015,
plus
forgiveness
of
your
due
balance
(30%
at
++
monthly
energy
charges
through
September
2015,
plus
forgiveness
ofencourage
your the
pastCARE
duetoProgram
balance
(30%
at
enrollment
Space
inbelow.
the
CARE
Program
isapply
limited,
and
spots
will
fill
quickly.
We
you
respond
soon
by
submitting
information
below.
Customers
who
apply
by mail
will
receive
notification
from
within
30
days.
information
Customers
who
by mail
will
receive
notification
from
the CARE
Program
within
30 days.
efficient!
the
remainder
throughout
the
program
year).
You
will
also
receive
offers
to
help
make
your
home
more
energy
theenclosed
remainder
throughout the program year). You will also receive offers to help make your home more energy
the
application.
efficient!
efficient!
If qualify
you in
qualify
to enroll
the CARE
program,
and stay
on your
you
will
receive
asoon
40%
credit
on your
If you
to enroll
inProgram
theinCARE
and spots
stay
current
your
payments,
you will
receive
a 40%
credit
on
your
Space
the
CARE
isprogram,
limited,
willcurrent
fillon
quickly.
Wepayments,
encourage
you
to respond
by
submitting
Sincerely,
monthly
energy
charges
through
September
2015,
plus
forgiveness
of
your
past
due
balance
(30%
at
enrollment
monthly
energy
charges
through
September
2015,
plus
forgiveness
of
your
past
due
balance
(30%
at
enrollment
+ +
the
enclosed
Space
ininthe
CARE
Program
isislimited,
spots
will
fill
quickly.
We
encourage
you
totorespond
soon
submitting
Space
theapplication.
CARE
Program
limited,and
and
spots
will
fill
quickly.
Weoffers
encourage
youmake
respond
soonbyby
submitting
the
remainder
throughout
the
program
year).
You
will
also
receive
to
help
your
home
more
energy
the the
remainder
throughout
the
program
year).
You
will
also
receive
offers
to
help
make
your
home
more
energy
application.
theenclosed
enclosed
CARE
Program application.
Team
efficient!
efficient!
Sincerely,
Consumers
Energy
Sincerely,
Sincerely,
Space
inCARE
the CARE
Program
is limited,
and spots
willquickly.
fill quickly.
We encourage
you
to respond
by submitting
Space
in Program
the
Program
is limited,
and spots
will fill
We encourage
you to
respond
soonsoon
by submitting
CARE
Team
APPLICATION SUBMISSION OPTIONS
the
enclosed
application.
the CARE
enclosed
application.
Consumers
Energy
Team
CAREProgram
Program
Team
The enrollment period begins October 1, 2014 and will continue until spots are filled.
Consumers
Energy
Consumers
Energy
Understand
the
key
program dates
Sincerely,
APPLICATION
SUBMISSION
OPTIONS
Sincerely,
Documents
signed before
October 1 will not be eligible.
APPLICATION SUBMISSION OPTIONS
APPLICATION
SUBMISSION
The
enrollment
period
begins
October
2014
continue
untilinspots
spots
arefilled.
filled.
The
enrollment
period
begins
October1,1,OPTIONS
2014
continue
until
Dial 2-1-1,
tell
the representative
youand
arewill
calling
to enroll
the are
Documents
signed
before
October
1
eligible.
Documents
signed
before
not
be
eligible.
The
enrollment
period
begins
October
1,
2014
and
will
continue
until
spots
are
filled.
The
enrollmentEnergy
period CARE
beginsprogram”
October and
1, 2014
will continue
untilnearest
spots are
filled.
“Consumers
they and
will direct
you to the
site.
Documents
signed
before
October
1
will
not
be
eligible.
Documents
signed
before
October
1
will
not
be
eligible.
Dial
2-1-1,
tell
the P.O.
representative
you
are calling
to
in to
theenroll in the
Enroll in-person with a
Contact
THAW
at (866)
281-0031,
tell the
representative
you
areenroll
calling
CARE
Program;
Box
26067;
Lansing,
MI
48909-9883
1
APPLICATION
SUBMISSION
OPTIONS
APPLICATION
SUBMISSION
OPTIONS
2
Submit
by
mail
partner
agency
“Consumers
Energy
CARE
program”
and
you
to
the
nearest
site.
“Consumers
Energy
CARE
program”
and
they
will
direct
nearest
site.
Dial
2-1-1,
tell
the
representative
you
are
calling
to
enroll
in
Enroll
in-person
with
a
mail-in
applications
only,
call
(877)
If
you
have
questions
or
concerns
about
Dial 2-1-1, tell the representative you are calling to enroll inthe
the448-9433.
Enroll in-person with a
11
partner
agency
The
enrollment
period
begins
October
1,
2014
and
will
continue
until
spots
are
filled.
“Consumers
Energy
CARE
program”
and
they
will
direct
you
to
the
nearest
The
enrollment
period
begins
October
1,
2014
and
will
continue
until
spots
are
filled.
partner
agency
“Consumers
Energy
CAREP.O.
program”
and they
direct
you to the nearestsite.
site.
Submit
your
application
by will
fax or
email
Understand
theprogram
key
program
dates
CARE
Program;
Box
26067;
Lansing,
MI
48909-9883
Understand
the
key
dates
3
Submit
by fax
email
Documents
signed
before
October
1
will
not
be
eligible.
2
Submit
by or
mail
CARE
Program;
607
Shelby
St.,
Suite
400,
Detroit
MI
48226
Documents
signed
before
October
1
will
not
be
eligible.
Fax: (877)
443 P.O.
– 3918
| Email:
applications
only,
call (877) 448-9433.
If you have questions
or
concerns
about
[email protected]
CARE
Box
Lansing,
CAREProgram;
Program;
P.O.
Box26067;
26067;
Lansing,MIMI48909-9883
48909-9883
22
Submit
bybymail
Submit
mail
mail-in
applications
only,
call
(877)
IfIfyou
concerns
about
Submit
your
application
by
fax calling
orto
email
Dial 2-1-1,
the representative
you
are
to
enroll
in(877)
the448-9433.
Enroll
in-person
Dialquestions
2-1-1,
tellorthe
representative
you
are
calling
enroll
in
the
Enroll
in-person
with
awith a
mail-in
applications
only,
call
448-9433.
youhave
have
questions
ortell
concerns
about
Submit
by fax
or email
1 31
partner
agency
Fax:Energy
(877)
443
–
3918
|
Email:
[email protected]
“Consumers
CARE
program”
and
they
will
direct
you
to
the
nearest
site.
partner
agency
“Consumers
Energy
CARE
program”
and
they
will
direct
you
to
the
nearest
site.
Submit
your
application
by
fax
or
email
Submit your application by fax or email
3CONSUMERS
Submit
bybyfax
ENERGY
CARE
PROGRAM
3
Submit
faxor
oremail
email
Fax:
(877)
443
–
3918
|
Email:
[email protected]
Fax:
(877)
443Box
– 3918
Email:
[email protected]
P.O. Box 26067, Lansing, MI 48909-9883
Program;
P.O.
Box |26067;
Lansing,
MI 48909-9883
CARECARE
Program;
P.O.
26067;
Lansing,
MI 48909-9883
2
Submit
by mail
2 ConsumersEnergy.com/assistance
Submit
by mail
mail-in
applications
call (877)
448-9433.
If
you
have
questions
or
concerns
about
call (877)
448-9433.
If you have questions or concerns about mail-in applications only, only,
CONSUMERS ENERGY CARE PROGRAM
Submit
your application
or email
P.O. Box 26067,ENERGY
Lansing,CARE
MI 48909-9883
Submit
your application
by faxbyorfax
email
PROGRAM
3CONSUMERS
Submit
byorfax
or
email
ENERGY
CARE
PROGRAM
3 CONSUMERS
Submit
by fax
email
Fax: (877)
443
– 3918
| Email:
[email protected]
ConsumersEnergy.com/assistance
Fax: (877)
443 –
3918
| Email:
[email protected]
P.O. Box 26067, Lansing, MI 48909-9883
CARE Program
Enroll
withdates
a
Understand
the in-person
keyTeam
program
CARE
1 Program Team
partner
agency dates
Consumers
Energy
Consumers
Energy
Understand
the
key
program
Understand the key program dates
P.O. Box 26067, Lansing, MI 48909-9883
ConsumersEnergy.com/assistance
ConsumersEnergy.com/assistance
CONSUMERS
ENERGY
PROGRAM
CONSUMERS
ENERGY
CARECARE
PROGRAM
CONSUMERS ENERGY
CARE 2.0 PROGRAM
ENROLLMENT APPLICATION
APPLICATION CHECKLIST
o
Must be 18 years or older to apply
o Completed, signed and dated application (must sign bottom of pages 3 and 7)
PLEASE INCLUDE
COPIES OF ALL
DOCUMENTS AND
DO NOT SUBMIT
ANY ORIGINAL
DOCUMENTATION.
o
Copy of most recent Consumers Energy bill
o
A copy of primary applicant’s Social Security Card and a listing of Social
Security numbers for all other members of the household (page 5)
o
Readable identification for applicant only (copy of one of the following government issued
photo IDs is required): Driver’s license, state ID, passport, or U.S. Military ID
o
Proof of all household income
• See page titled “Acceptable Forms of Income”
• Sources may include any of the following: Pay stubs, which must span four current weeks
in a row within the past 60 days; employment letters/statements; unemployment letters/
statements; Social Security and pension letters/statements; worker’s compensation letter/
statement; child support verification; Friend of the Court letters/statements or check stubs;
divorce decree; check stubs/receipts; disability letters/statements; interest, annuity or dividend
letters/statement; federal or state tax forms
o
EASE survey (tier one with EASE survey completion guide) at the end of this packet
Please understand that providing incomplete information within your submitted application
packet will delay processing. CARE application packets may not be signed and dated before
October 1st.
1014
HELPING MICHIGAN SAVE ENERGY. THAT’S OUR PROMISE.
ACCEPTABLE FORMS OF INCOME
All income verification documentation MUST include:
• Employee or recipient name
• Employer or source name
• Pay date and/or pay period
• Gross (before taxes & deductions) amount of pay
• A summary of any income deductions
1. HOUSEHOLD WAGE OR BUSINESS INCOME (only one of the below):
• Paystubs: If paid weekly, must receive four paystubs in date order for one full month. If paid bi-weekly, must receive two
paystubs in date order for one full month. Must NOT be older than 60 days.
• Print off from employer (must be for a full 30 days, must NOT be older than 60 days, and must be in a row)
• Letter from employer (must be for a full 30 days, must NOT be older than 60 days, must be on company letterhead and
signed by an authorized supervisor)
2. OTHER/FIXED INCOME:
• SSI, Social Security, RSDI, SSDI, SDA and/or Pension
• Social Security award letter must NOT be dated older than 60 days. If the award letter is dated older than 60 days,
also send a copy of bank statement showing deposits from received benefits within the last 60 days (for your own
security cross out the bank account number), tax return, copy of check, or DHS Ml Bridges printout. Only one of the
above required.
• Child Support
• A printed summary from courts or website, or bank statement showing deposit from Friend of the Court (for your own
security cross out the bank account number).
• Workers Compensation
• Workers compensation award letter must NOT be dated older than 60 days. If the award letter is dated older than 60
days, also send a copy of bank statement showing workers compensation deposits within the last 60 days (for your
own security cross out the bank account number).
• Unemployment
• Current unemployment award letter must NOT be dated older than 60 days. If the award letter is dated older than 60
days, also send a copy of bank statement showing unemployment insurance deposits within the last 60 days (for your
own security cross out the bank account number), or a printed summary from the unemployment insurance website or
a printed summary from Ml Bridges printout. Only one of the above required.
• Adoption Subsidy/Direct Care through the State of Michigan
• Pay stubs or bank statement showing deposit from the state of Michigan (for your own security cross out the bank
account number).
• Alimony or spousal support
• Divorce agreement and bank statements or interest, annuities or dividends statements (for your own security cross
out the bank account number). Only one of the above required.
3. SELF-EMPLOYMENT:
• Must complete attached self-employment affidavit (included in this packet)
• Federal or state tax forms
• Self-employment profit and loss statement
4. NO INCOME:
• If there is ZERO income for all members of the household, please enter that on the application and complete attached
zero income affidavit (included in this packet)
Consumers Energy CARE 2.0 Program Enrollment Application l 2 of 9
BRINGING ENERGY AFFORDABILITY
TO MICHIGAN
What you’ll get...
What you’ll do...
A 40% discount on your bill until September 2015. For
example, if your energy charges were $100:
Make on-time monthly payments toward a more
affordable bill
$100 monthly energy usage
- $40 CARE credit
$60 + any late or other non-energy charges
Access to an online survey tool about energy use, called
EASE (Everyday Actions Save Energy) that provides a
home report with easy tips on energy savings.
An invitation to have an Energy Expert visit your home
for free through a program called Helping Neighbors.
Depending on your home’s condition, you may receive:
• Water heating and lighting measures
• A carbon monoxide test
• Air sealing
Complete the initial EASE survey with your caseworker
and, if you wish, log in again on your own to take a
second survey for more tips.
Talk about and set 3 energy saving goals with the
Energy Expert. These are simple steps you can take
around the house to use less energy and save even
more on your bill.
• A furnace tune-up
• Insulation
A friendly Agency Caseworker, who will help you better
understand the CARE Program and is someone you can
call if you have questions or need extra support.
• Name:
While on CARE, understand that you cannot:
• Apply for the State Emergency Relief (SER) energy
benefit from DHS for your Consumers Energy
service
• Be on any other Consumers Energy payment plan
at the same time as CARE
• Agency:
• Make payment arrangements on any past-due
balance
• Phone number:
If you cannot pay your bill by the due date, you will receive
a courtesy past-due reminder call 11 days following the
due date. This call is a warning that, unless payment is
received within one week, you will be removed from CARE.
If you are removed from CARE due to nonpayment, you
cannot:
• Re-enroll in CARE this year
• Enroll in the Shut-Off Protection Plan (SPP) until
October 2015
If you are removed from CARE, you can:
• Apply for the State Emergency Relief (SER) energy
benefit from DHS for your Consumers Energy
service until November 2015
• Make payment arrangements on the past-due
balance
• Enroll in the Winter Protection Plan (WPP)
I understand and agree to enroll in the CARE Program.
/
PRINTED NAME
SIGNATURE
/
DATE (MUST BE OCT. 1 OR LATER)
REQUIRED INFORMATION
PRIMARY ACCOUNT HOLDER INFORMATION
NAME OF CONSUMERS ENERGY ACCOUNT HOLDER (FIRST NAME, MIDDLE INITIAL, LAST NAME)
SOCIAL SECURITY NUMBER
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
MI
MI
PRIMARY PHONE NUMBER
o
Cell phone
o
Permission to text updates
o
Cell phone
o
Permission to text updates
SECONDARY PHONE NUMBER
BEST CONTACT TIME:
o
o
WEEKDAY:
WEEKEND:
o Morning
o Morning
EMAIL ADDRESS
o Afternoon
o Afternoon
GENDER
o M
ARE YOU DISABLED?
o Yes
o No
o Evening
o Evening
ETHNICITY
o
ARE YOU A VETERAN?
o Yes
o No
F
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 last three years?
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
o
Medical hardship
o
Other (explain):
Consumers Energy CARE 2.0 Program Enrollment Application l 4 of 9
HOUSEHOLD INFORMATION
Customer to complete table. Total number of members, including the applicant, in the household:
RELATIONSHIP
TO APPLICANT
FIRST NAME
MI
FULL LAST NAME
FULL SSN
DATE OF
BIRTH
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.
HOUSEHOLD WAGE OR BUSINESS INCOME
Do any of the household members receive income?
No income: If no-one in your household receives income, you must complete the No Income Affidavit (P8) and
return it in the envelope provided with your application.
o
Yes
o
No
Are you or another household member employed?
If yes, it is necessary to complete the income validation table below and include proof of income and return it
in the envelope provided with your application. A full 30 days of paycheck stubs is required and these samples
may not be dated more than 60 days from the date you sign on your CARE application.
o
Yes
o
No
Of the household members who are employed, are any self-employed?
If yes, each self-employed household member must complete the Self-Employed Affidavit (P7) and return in the
envelope provided with your application.
o
Yes
o
No
FIRST & LAST NAME
GROSS EARNINGS
EMPLOYER’S NAME
PAY FREQUENCY
(BEFORE TAXES)
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
$
Consumers Energy CARE 2.0 Program Enrollment Application l 5 of 9
OTHER HOUSEHOLD INCOME
INCOME
SOURCE CODES
Does anyone in your household receive any unearned income? If yes, it is necessary to complete the income
validation table below and include proof of income and return it in the envelope provided 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. Supplemental Security Income (SSI)
7. Worker’s compensation
8. Child support (received)
9. Tribal payments
10. Adoption subsidy
INCOME
SOURCE CODE
o
Yes
o
No
11. Disability benefits
12. Unemployment compensation
13. Rental income
14. Other:
PAY FREQUENCY
AMOUNT RECEIVED
$
$
$
$
$
$
$
$
ELIGIBLE EXPENSES
Does your household pay any of the following expenses? If yes, check all that apply and attach proof.
FIRST & LAST NAME
EXPENSE
o
Yes
o
No
MONTHLY AMOUNT PAID
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 6 of 9
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.
SIGNATURE:
DATE:
(MUST BE OCT. 1 OR LATER)
Consumers Energy CARE 2.0 Program Enrollment Application l 7 of 9
SELF-EMPLOYMENT AFFIDAVIT
This affidavit is to be signed by any individual who is 18 years of age and over 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.
• This estimated earnings is supported by:
o
1040 Form & 1040 Schedule C
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:
(MUST BE OCT. 1 OR LATER)
Consumers Energy CARE 2.0 Program Enrollment Application l 8 of 9
ZERO INCOME AFFIDAVIT
• Applicant name:
• Address:
I hereby certify that any person in my household does not receive 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 allowaces such as alimony, child support or gifts received
• Sales from self-employment
• Any other source not named above
SIGNATURE:
DATE:
(MUST BE OCT. 1 OR LATER)
Consumers Energy CARE 2.0 Program Enrollment Application l 9 of 9
EASE
TIER 1
SURVEY
Welcome to the Everyday Actions Save Energy
(EASE) Survey. This short 8-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
STREET ADDRESS
CITY, STATE
ZIP
Please answer all questions. If you’re unsure, we ask that you make your best guess.
PART 1: HEATING, VENTILATION & AIR CONDITIONING (HVAC) SYSTEM IN YOUR HOME
1. What type of heating system do you have?
oElectric baseboard or wall heaters
oPropane/LP gas furnace (deliverable fuel)
oGas furnace (forced air)
o
Other (please specify)____________________
o Before 1985
o
1995-1999
o 1985-1989
o
2000 or newer
oGas boiler (radiators/steam pipes)
2. When was your heating system installed?
o 1990-1994
3. What kind of air conditioning system do you have?
o Central electric A/C
o Other (Please specify)____________________
o
o None (Please skip to question 5)
Electric window or wall units
o Central gas A/C
4. When was your air conditioning system installed?
o Before 1985
o 1995-1999
o 1985-1989
o 2000 or newer
o 1990-1994
PART 2: HOUSEHOLD MEMBERS
5. How many people live in your household on a full-time basis?
Number of residents _________________________
Consumers Energy EASE Tier 1 Survey
l
2 of 3
PART 3: WATER HEATING SYSTEM IN YOUR HOME
6. What kind of water heater do you have?
o Electric
o Gas
o Propane
o Other (Please specify)____________________
Electric water heater is plugged into an outlet
Natural gas or propane water heater is vented
PART 4: SIZE AND AGE OF YOUR HOME
7. How big is your home?
o Less than 1,000 sq. ft. (average small apartment)
o 1,000-1,499 sq. ft. (average large apartment or ranch-style home)
o 1,500-1,999 sq. ft. (average two-story home)
o 2,000-2,499 sq. ft. or larger (average two-bedroom home with finished basement)
8. How old is your home?
o Before 1950
o 1980-1989
o 1950-1959
o 1990-1999
o 1960-1969
o 2000 or newer
o 1970-1979
Thank you for completing the EASE survey.
Consumers Energy EASE Tier 1 Survey
l
3 of 3