Dear Friend,

The Heat and Warmth Fund (THAW), a leading provider of energy assistance, wants to make it easier for you to get the help you need. If you are struggling to pay your energy bill, you can now apply for

Applying for THAW assistance is as easy as 1,2,3:

YOU CAN NOW APPLY ONLINE: thawfund.org• Create your own account

• Complete and save • Track status

• Communicate with a THAW Assistance Specialist

1. Review 2016 Program Guidelines to see if you meet eligibility requirements. (refer to the Document Checklist)

be made directly to your energy provider. It may take up to 30 days for THAW assistance to be re-

and the amount of your assistance payment.

Submit an via THAW’s website, mail, fax or email: Online: thawfund.org Mail: The Heat and Warmth Fund, 535 Griswold, Suite 200 Detroit, MI 48226 Fax: 1-888-618-1081 Email: help@thawfund.org

1-800-866-THAW (8429) to speak to a THAW energy assistance specialist.

Learn more at thawfund.org or by calling 1-800-866-THAW (8429)

Thank you,Saunteel Jenkins

The Heat and Warmth Fund

DOWNLOAD MEAP1516

by calling 1-800-866-8429

$10.503.6@ 2.605400 $9.383.6@ 0.303000 $1.093.6@ 4.793700 $17.26

$38 .23

Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

0 0 0 0 0 1

7.7

1314.6

15.814.1

8.5

3.6

2012 2013

$1.32

Service:

$690 .04$20.15

Reminder- Previous balance was due 05/30/13. Please pay thepast-due amount to avoid credit action. Thank you.

Payments applied after Jun 06, 2013 are not included.

$38.23$1.53

$39 .76$15.00$15.00

$779 .95Cash/Money Order Only

June29

Invoice 205541370523

Your payment is due July 01, 2013. After the due date, the unpaidbalance is subject to a 2% late payment charge.

The average residential customer is expected to save $3.54each month over the life of the Energy programs.

Authorized Pay Agents. Kmart andWalmart are nowamong the authorized merchants throughout Michiganthat accept payments on behalf of Consumers Energy. Forsites near you, visit www.ConsumersEnergy.com andchoose "Payment Options." For your safety, DO NOT USEUNAUTHORIZED PAYMENT CENTERS.

For more than 100 ways to save on your energy bill, visitwww.ConsumersEnergy.com/EnergyAnswers.

Natural Gas Safety and Reliability. We are committed to providing safe, reliable natural gas service whileprotecting the health and safety of our neighbors who live or work near our pipelines and facilities.

Get safety tips and learn what to do in an emergency at www.ConsumersEnergy.com/gascenter.

Due: 07/01/13 Enclosed:

Total: $779.95

Visit: www.ConsumersEnergy.com

APPLICATION

x

Please use this checklist to make sure you are including all appropriate

restored.

DOCUMENT CHECKLIST

Copy of valid photo ID for the account holder, i.e. Driver’s license or state issued ID:• The address on the ID must match the service address on the account. If not, you must

Copy of Social Security cards for all household members, including minors:

•

• or Other Fuel Vendor Invoice:• The invoice will document the amount of fuel provided and

Copy of 60 Days Proof of Income for ALL members of the household:

• •

annually (form included within this packet)

Paycheck

Stub

Social

Secur

ity

Statem

entSSI

Statemen

t

TANF S

tateme

nt

or

or

or

I

• Self income exceeding $8,500 must provide proof

one of the followingpieces of documentation:

DOWNOAD MEAP1516

THAW ENERGY ASSISTANCE2015-2016 ENERGY/GAS ASSISTANCE PROGRAM GUIDELINES

Eligibility:• Total owing cannot exceed $2,000 for combined (gas and electric) accounts or $1,000 for single

accounts (gas or electric)

• Account must be in the applicant’s name; if the account is not in the applicant’s name he/she must accept responsibility for the bill with a valid ID or Driver’s License

- The person at the appointment MUST have all required documents need on their behalf - A signed from the account holder them permission to apply on their behalf• Account must be (not a commercial account)• Applicant must pay illegal or unauthorized usage charges and security fees• Accounts MUST have a past due balance (usage arrearage)• If services are not restored within 30 days of THAW commitment, funds will be removed from the -

count. Clients must have service within 30 days

Income:• Proof of households income is required. • A household is income eligible with an income of not more than 150% of the federal poverty

guidelines. The following 2015 Federal Poverty Guidelines for monthly income will be in effect

Family Size: 1 Person 2 Person 3 Person 4 Person 5 Person 6 Person 7 Person Income $1,471.25 $1,991.25 $2,511.25 $3,031.25 $3,551.25 $4,071.25 $5,111.25

Please Note:• Following services do not qualify as usage arrearage:

- unauthorized or illegal usage - provider late fees - provider unregulated services (appliance repair) - bankruptcy - cooking gas

• Applicants eligible to receive THAW MEAP assistance if enrolled in DTE Energy’s LSP, Consumer Energy’s CARE and/or SEMCO Energy’s MAP program

ac

ALL members

may not be

1

I hereby make applica on for the Michigan Energy Assistance Program (MEAP). I understand that there may be a delay in processing if there is missing informa on. The MEAP crisis season runs from November 1 through May 31 therefore emergency assistance may not be available June 1 through October 31.

Michigan Energy Assistance Program

Household Information

List everyone who lives in your home, including adults and children temporarily absent due to illness or employment. People are considered members of your household if they sleep and keep their

Name Social Security Number Date of Birth

Yes No Name Social Security Number Date of Birth

Yes No Name Social Security Number Date of Birth

Yes No Name Social Security Number Date of Birth

Yes No Name Social Security Number Date of Birth

Yes No

Household Address (Service Address) Address (Numbers & Street Name, Apt., etc.)

SELF

City

State County Zip Code

Mailing Address, if di erent than above Address (Numbers & Street Name, Post Office Box) City

State County Zip Code

Additional Information Needed Home Heating Credit (HHC): Have you applied for or received the HHC (Energy Draft) in the last 6 months?

Yes, month received________ No

Have you or do you currently receive benefits from Department of Health and Human Services (DHHS)? Yes No

Have you received energy assistance from another agency or through a provider-sponsored program since October 1?

Yes, who was the provider(s):____________________

No ___________________

How do you heat your home?

Natural Gas Fuel Oil

Propane Electric Heat

Wood Coal

Other______________

Emergency Need: Check the service(s) that you

the emergency for 30 days.

Household Heating $_____________ If this is a prepaid account, amount in account $ _____________ *If deliverable fuel, percentage remaining in tank ___________%

t of the fuel remaining in your tank

Electricity (non- ___________________ If this is a prepaid account, amount in account $____________

Name Social Security Number Date of Birth

Yes No

30

Number of pregnant individuals in the household

Do you own or rent your home? OWN RENT

Is the applicant a veteran?

DOWNLOAD MEAP1516

Is the applicant disabled? Yes No

Yes No

2

Electric (non-heat) Provider Information Name and address of company/energy provider

Service address Name on account

Account number

Has your electricity been turned o�? No

Have you received a past due or shut o� notice for your electricity? Yes, when is service scheduled to be turned off:______________

Yes, date service was turned off:______________

No

Household Heating Provider Information Name and address of company/energy provider

Service address Name on account

Account number

Has your heat been turned o� or have you run out of your only No

Have you received a past due or shut o� notice for your heat or are you at risk of running out of your household heating fuel? service is scheduled to be shut off:__________

Yes, date heat was turned off or when fuel ran out:_____________

No

Household Income

Please check all sources of income that your household expects to receive in the next 30 days

Does your household have any income? No Yes, Total monthly Income:$___________

Social Security

Supplemental Security Income (SSI)

Disability benefits

Self-employment income

Employment/earned income

Unemployment

Money from family/friends

Veteran’s Benefits/ Military Allotments Child Support ________________________________

Tribal payments (Energy Assistance/LIHEAP, tribal GA, casino/gambling profit sharing, land claims, etc.)

Rental income or a land contract, mortgage or other payment payable to a household member

Person with income Type of income (if employed, name of employer)

Gross Monthly Income (Amount before taxes and expenses)

(Weekly, biweekly, monthly, etc.)

Have there been any changes or do you expect a change in your house-hold income in the next 30 days? No Yes, Please briefly explain below:

DOWNLOAD MEAP1516

3

for each.

Income Expenses

$

Health Insurance Premium

Amount

$

Court ordered child support

Amount

Actual child care costs paid by an employed household member, not DHHS Amount

$

Unusual employment related expenses

Amount

$ Explain Expense

Signature Requirement

verify my eligibility for assistance.

Michigan Energy Assistance Program (MEAP). I authorize my energy company to release by phone, fax, email or their computer web site all available

UNDER PENALTIES OF PERJURY, I SWEAR OR AFFIRM THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO ME. IF I AM A THIRD PARTY APPLYING ON BEHALF OF ANOTHER PERSON, I SWEAR THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO THE APPLICANT. TO THE BEST OF MY KNOWLEDGE, THE FACTS ARE TRUE AND COMPLETE.

Signature of applicant or head of household Date Signature of spouse Date

Address (Numbers & Street Name, Apt., etc.) Date

Current phone number

Request for Review

in 10 u or your

of this form.

guarantee payment of funds, even if preliminary approval is granted. I hereby release THAW Fund, its employees, officers, directors and its partnering

DOWNLOAD MEAP1516

Applicant Name: ____________________________________________________________________________________ Address: __________________________________________________________________________________________

a. b. c. Rental income from real or personal property;d. e. Unemployment or disability payments;f. Public assistance payments;g. h. Sales from self-employment;i. Any other source not named above.

Signature ________________________________________________ Date __________________________

I am self-employed in the business of: ___________________________________________________________________

I have been self-employed in this manner since: ____/_____/_________

❒ previous year’s tax return ❒ accountant’s/bookkeeper’s statement ❒ business receipts/check stubs ❒ other _______________________________________________

If none of the above is available, please state the reason why: ________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Signature ________________________________________________________ Date __________________________DOWNLOAD MEAP16

DOWNLOAD MEAP16