ENERGY ASSISTANCE PROGRAMS APPLICATION JULY 2020 – MAY 2021

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 Plus (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, 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, it can take up to 12 weeks to process. Please note: HEAP benefits will be
applied to your utility bill starting in January.

Here’s what you’ll need to complete this application:

• Proof of citizenship for each household member • Copies of your most recent utility bills
• Proof of income for each household member for the • Disability verification (if applicable)
previous 30 days or 12 months
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 & electric) • A legal fireplace (wood)
• A permanent, free-standing fuel tank (oil & propane) • 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 for payment assistance.
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 energy bill by the utility company. If you
are reverifying your PIPP amount, it will be based on either 10% or 6% 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) • Home Weatherization Assistance Program (HWAP)
• Percentage of Income Payment Plan Plus (PIPP)
2020–2021 Income Guidelines
Size of Household Total Gross Annual Household Income
1 up to $19,140 $22,330 $25,520
2 up to $25,860 $30,170 $34,480
3 up to $32,580 $38,010 $43,440
4 (150%) up to $39,300 (175%) $45,850 (200%) $52,400
5 (For PIPP, EPP) up to $46,020 (For HEAP, $53,690 (For HWAP) $61,360
6 up to $52,740 WCP and SCP) $61,530 $70,320
7 up to $59,460 $69,370 $79,280
8 up to $66,180 $77,210 $88,240
When determining 150% of the federal poverty guidelines, households with more than eight members must add $6,720 to the yearly income or
$552.33 to the 30-day income for each additional member. When determining 175% of the federal poverty guidelines, households with more
than eight members must add $7,840 to the yearly income or $644.38 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 $8,960 for each additional member.

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.
If you have questions, please contact your local Energy Assistance Provider or call 1-800-282- 0880.
TDD hearing impaired only: 711 or send us a message by visiting energyhelp.ohio.gov and clicking “contact us”.
The State of Ohio is an Equal Opportunity Employer and Provider of ADA Services.
Accepted Citizenship Documentation
Proof of U.S. Citizenship Proof of Legal Resident/Qualified Alien
1. Birth Certificate/Hospital Birth Records 1. Naturalization Papers/Certifications of Citizenship
2. Baptismal Records 2. INS ID Card
(Only when place and date of birth is 3. Alien Registration Cards/Re-entry permits
shown)
4. INS Form I-151 or I-551 (Form I-151 will not be valid after August 1,
3. Indian Census Record 1993)
4. Military Service Record 5. INS Form I-94 if annotated with either: a) Sections 203(a)(7), 207,
5. U.S. Passport 208, 212(d)(5), 243(h), or 241(b)(3) of the Immigration and Nationality
6. Verified Citizenship for Ohio Works First Act: or b) One or a combination of the following terms: Refugee,
(OWF) Program Parolee, or Asylee

7. Voter Registration Cards 6. Permanent Visa INS Form G-641, “Application for verification of
Information from INS Records”, when annotated at bottom by INS
8. Social Security Cards representative as lawful admission for humanitarian reasons
(Social Security Cards administered by
Social Security Administration that do not 7. Documentation that alien is classified pursuant to Sections: 101(a)(2),
include notes regarding work authorization 203(a), 204(a)(1)(a), 207, 208, 212(d)(5), 241(b)(3), 243(h), or 244(a)(3), of
status will be accepted). the Immigration and Nationality Act
8. Court order stating that deportation has been withheld pursuant to

Please tear here and keep instructions for your records

Section 241(b)(3) or 243(h) or of the Immigration and Nationality Act
9. INS Form I-688

Accepted Proof of Income

Fixed Earned Employment Supplemental Other Sources of Other Earned
Income Income Income Income Income

Award/Benefit All pay stubs Copy of check/ Statement Pay stubs

letter received 30 days award amount from Financial indicating amount
from the date of letter Institution received within
Payment printout/ the application the previous 12
statement from that include gross ODJFS documents/ Copy of check or months from
issuing agency and year-to-date eligibility letter bank statement the date of the
amounts received with amounts showing deposit application
Copy of check or and dates
bank statement Most recent IRS
Completed Self-Employment
showing deposit and signed Most recent IRS Form 1099 Income and
Employment Form 1099 Expense Form
Most recent filed
IRS Form 1040 Verification Form Housing Authority for the previous
Documentation 12 months (form
Most recent IRS can be found at
Form 1099 Pay Stubs received energyhelp.ohio.gov)
within the previous
30 days from Most recent filed
the date of the IRS Form 1040
application and Schedule 1

Payment printout/ Most recent IRS

statement from Form 1099
issuing agency

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.
Personal Information Section Client Number

Enter the information completely. PLEASE USE DARK BLUE OR BLACK INK.
Failure to fill out the application completely, provide all the required documentation
and sign the application will delay the processing of your application.
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

  Yes     No   Female     Male  Hispanic, Latino or Spanish Origins     Not Hispanic, Latino or Spanish Origins

Race
  American Indian/Alaskan Native   Asian   Native Hawaiian/Other Pacific Islander

  American Indian/Alaskan Native &   Asian/White   Other Multi-Race

Black/African American
  Black/African American   White
  American Indian/Alaskan Native & White
  Black/African American/White

Non-Cash Number of Household

Benefits   Supplemental Nutrition Assistance Program   Housing Choice Voucher   Women, Infants, and Children (WIC) Members
(SNAP) / Food Stamps
  HUD-VASH   Other
  Affordable Care Act Subsidy
  Permanent Supportive Housing
  Child Care Voucher

Family Type Housing Type Residence Structure

  Single Parent/Male   Non-related Adults with Children   Own   Mobile Home

  Single Parent/Female   Multigenerational Household   Rent   Single-Family

  Two-Parent Household   Other   Multi-Family Low Rise (3 stories or less)

  Single Person   Multi-Family High Rise (4 stories or more)

Email Address Phone Number (including area code)

(       )
Preferred Method of Contact*
 Email    Postal

Mailing Address (number and street including route)* Apt/Lot/Unit/Floor

City* State* Zip Code* County*

Is Utility Service Address the Same?*

  Same as above     Different (list below)

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)

  Yes     No

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*

If you have additional household members (anyone living under your roof at the same address), please complete
page 2 of the application. 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.
*Indicates required information in order to process your application.  Failure to fill out the application completely,
provide all the required documentation and sign the application will delay the processing of your application.
Page 1 of 6 u
Household Members Section
Complete for anyone living in your home.
Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Gender Ethnicity

  Yes     No   Female     Male  Hispanic, Latino or Spanish Origins     Not Hispanic, Latino or Spanish Origins

Race U.S. Citizen / Legal Resident (Qualified Alien)*

  American Indian/Alaskan Native   Asian   Native Hawaiian/
Other Pacific Islander
  American Indian/Alaskan Native &   Asian/White   Yes     No
Black/African American   Other Multi-Race
  Black/African American
  American Indian/Alaskan Native & White   White
  Black/African American/White

Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Gender Ethnicity

  Yes     No   Female     Male  Hispanic, Latino or Spanish Origins     Not Hispanic, Latino or Spanish Origins

Race U.S. Citizen / Legal Resident (Qualified Alien)*

  American Indian/Alaskan Native   Asian   Native Hawaiian/
Other Pacific Islander
  American Indian/Alaskan Native &   Asian/White   Yes     No
Black/African American   Other Multi-Race
  Black/African American
  American Indian/Alaskan Native & White   White
  Black/African American/White

Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Gender Ethnicity

  Yes     No   Female     Male  Hispanic, Latino or Spanish Origins     Not Hispanic, Latino or Spanish Origins

Race U.S. Citizen / Legal Resident (Qualified Alien)*

  American Indian/Alaskan Native   Asian   Native Hawaiian/
Other Pacific Islander
  American Indian/Alaskan Native &   Asian/White   Yes     No
Black/African American   Other Multi-Race
  Black/African American
  American Indian/Alaskan Native & White   White
  Black/African American/White

Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Gender Ethnicity

  Yes     No   Female     Male  Hispanic, Latino or Spanish Origins     Not Hispanic, Latino or Spanish Origins

Race U.S. Citizen / Legal Resident (Qualified Alien)*

  American Indian/Alaskan Native   Asian   Native Hawaiian/
Other Pacific Islander
  American Indian/Alaskan Native &   Asian/White   Yes     No
Black/African American   Other Multi-Race
  Black/African American
  American Indian/Alaskan Native & White   White
  Black/African American/White

Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Gender Ethnicity

  Yes     No   Female     Male  Hispanic, Latino or Spanish Origins     Not Hispanic, Latino or Spanish Origins

Race U.S. Citizen / Legal Resident (Qualified Alien)*

  American Indian/Alaskan Native   Asian   Native Hawaiian/
Other Pacific Islander
  American Indian/Alaskan Native &   Asian/White   Yes     No
Black/African American   Other Multi-Race
  Black/African American
  American Indian/Alaskan Native & White   White
  Black/African American/White

Page 2 of 6 u
Household Income Section*
Fill out the table below for all household members. Use additional section (on page 4) as needed for other household
members with income.
First Name Last Name

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† Other Earned Income†

  Social Security   Wages   Unemployment   Cash withdrawn from IRAs /   Self-employment

Annuities / Other Investments (includes owning own business,
  Supplemental Security (SSI)   Active Military Pay   Utility Assistance babysitting, home party sales,
  Interest Income odd jobs, Ohio Electronic Child
  Social Security Disability   Workers’ Compensation Care, etc.)
Insurance (SSDI)   Lump Sum Payouts
  Ohio Works First (TANF, ADC) ( Estate & Trust Settlements /
  Seasonal-employment
  Pension (Private & VA) Divorce Settlements / Insurance
  Employment Disability Payout (includes teachers,
Payout / Lottery Winnings)
  Widow/Widower’s Benefit construction workers, etc.)
  Strike Benefit
  Other
  Alimony †
These categories MUST provide
12 months of income documentation
  Black Lung Pension

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

$ $ $ $ $
First Name Last Name

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† Other Earned Income†

  Social Security   Wages   Unemployment   Cash withdrawn from IRAs /   Self-employment

Annuities / Other Investments (includes owning own business,
  Supplemental Security (SSI)   Active Military Pay   Utility Assistance babysitting, home party sales,
  Interest Income odd jobs, Ohio Electronic Child
  Social Security Disability   Workers’ Compensation Care, etc.)
Insurance (SSDI)   Lump Sum Payouts
  Ohio Works First (TANF, ADC) ( Estate & Trust Settlements /
  Seasonal-employment
  Pension (Private & VA) Divorce Settlements / Insurance
  Employment Disability Payout (includes teachers,
Payout / Lottery Winnings)
  Widow/Widower’s Benefit construction workers, etc.)
  Strike Benefit
  Other
  Alimony †
These categories MUST provide
12 months of income documentation
  Black Lung Pension

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

$ $ $ $ $
First Name Last Name

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† Other Earned Income†

  Social Security   Wages   Unemployment   Cash withdrawn from IRAs /   Self-employment

Annuities / Other Investments (includes owning own business,
  Supplemental Security (SSI)   Active Military Pay   Utility Assistance babysitting, home party sales,
  Interest Income odd jobs, Ohio Electronic Child
  Social Security Disability   Workers’ Compensation Care, etc.)
Insurance (SSDI)   Lump Sum Payouts
  Ohio Works First (TANF, ADC) ( Estate & Trust Settlements /
  Seasonal-employment
  Pension (Private & VA) Divorce Settlements / Insurance
  Employment Disability Payout (includes teachers,
Payout / Lottery Winnings)
  Widow/Widower’s Benefit construction workers, etc.)
  Strike Benefit
  Other
  Alimony †
These categories MUST provide
  Black Lung Pension
12 months of income documentation

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

$ $ $ $ $

Page 3 of 6 (OVER) u
Household Income Section – Continued
Fill out the table below for additional household members.
Print additional pages, as needed, for other household members with income.

First Name Last Name

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† Other Earned Income†

  Social Security   Wages   Unemployment   Cash withdrawn from IRAs /   Self-employment

Annuities / Other Investments (includes owning own business,
  Supplemental Security (SSI)   Active Military Pay   Utility Assistance babysitting, home party sales,
  Interest Income odd jobs, Ohio Electronic Child
  Social Security Disability   Workers’ Compensation Care, etc.)
Insurance (SSDI)   Lump Sum Payouts
  Ohio Works First (TANF, ADC) ( Estate & Trust Settlements /
  Seasonal-employment
  Pension (Private & VA) Divorce Settlements / Insurance
  Employment Disability Payout (includes teachers,
Payout / Lottery Winnings)
  Widow/Widower’s Benefit construction workers, etc.)
  Strike Benefit
  Other
  Alimony †
These categories MUST provide
12 months of income documentation
  Black Lung Pension

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

$ $ $ $ $
First Name Last Name

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† Other Earned Income†

  Social Security   Wages   Unemployment   Cash withdrawn from IRAs /   Self-employment

Annuities / Other Investments (includes owning own business,
  Supplemental Security (SSI)   Active Military Pay   Utility Assistance babysitting, home party sales,
  Interest Income odd jobs, Ohio Electronic Child
  Social Security Disability   Workers’ Compensation Care, etc.)
Insurance (SSDI)   Lump Sum Payouts
  Ohio Works First (TANF, ADC) ( Estate & Trust Settlements /
  Seasonal-employment
  Pension (Private & VA) Divorce Settlements / Insurance
  Employment Disability Payout (includes teachers,
Payout / Lottery Winnings)
  Widow/Widower’s Benefit construction workers, etc.)
  Strike Benefit
  Other
  Alimony These categories MUST provide
†

12 months of income documentation

  Black Lung Pension

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

$ $ $ $ $
First Name Last Name

Fixed Income Earned Employment Income Supplemental Income Other Sources of Income† Other Earned Income†

  Social Security   Wages   Unemployment   Cash withdrawn from IRAs /   Self-employment

Annuities / Other Investments (includes owning own business,
  Supplemental Security (SSI)   Active Military Pay   Utility Assistance babysitting, home party sales,
  Interest Income odd jobs, Ohio Electronic Child
  Social Security Disability   Workers’ Compensation Care, etc.)
Insurance (SSDI)   Lump Sum Payouts
  Ohio Works First (TANF, ADC) ( Estate & Trust Settlements /
  Seasonal-employment
  Pension (Private & VA) Divorce Settlements / Insurance
  Employment Disability Payout (includes teachers,
Payout / Lottery Winnings)
  Widow/Widower’s Benefit construction workers, etc.)
  Strike Benefit
  Other
  Alimony †
These categories MUST provide
12 months of income documentation
  Black Lung Pension

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

$ $ $ $ $

Page 4 of 6 u
Household Deductions Section*
Total Household Income Deductions (Choose all that apply)
  Attorney fees for estate or trust   Health Care Spending Accounts   Reimbursement for work expenses
settlements
  Medicaid Spend Down (deductibles)   Self-employment IRS allowable business
  Child Support paid-out expenses
  Medicare Premiums
  Health Insurance Premiums   Short and long term disability
  Prescription Plans

Total Deductions for the past 30 Days Total Deductions for the past 12 Months

$ $
Please note: Documentation of deduction(s) is required.

Total Household Eligible Income Section*

Please add the total income received for each adult household member then subtract the total household deductions.

Past 30 Days Past 12 Months

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)
– $ – $
Total Household Income less Total Household Deductions above Total Household Income less Total Household Deductions above

Total Eligible Income $ $

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*

How do you heat your home?
  Natural Gas   Fuel Oil or Kerosene   Electric (Includes baseboards)

  Propane or Bottle Gas (L.P. Gas)   Coal, Wood, or Pellets   Other

Company/Vendor Account Number Costs included in rent? Shared Meter?

  Yes     No   Yes     No

Account Holder’s First Name Account Holder’s Last Name Relationship to Primary Client

Do you wish to apply for HEAP? If you are currently enrolled in PIPP, do you wish to reverify on this account?
  Yes     No   Yes     No

Do you wish to enroll in PIPP and have a regulated utility provider?

  Yes     No

Please provide your electric utility provider information (if not provided above):
Electric Company/Vendor Account Number Costs included in rent? Shared Meter?
  Yes     No   Yes     No

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?
  Yes     No

Do you wish to enroll in PIPP and have a regulated utility provider?

  Yes     No

Page 5 of 6 u
ENERGY ASSISTANCE PROGRAMS APPLICATION JULY 2020 – MAY 2021
Terms of Agreement
I agree To pay my Percentage of Income Payment Plan Plus (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 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 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
Development Services Agency 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 Development Services Agency 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 Development Services Agency, 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 Development Services Agency, and the Director of the Ohio Department of Jobs and Family Services.
I understand that by signing this application, I grant the Ohio Development Services Agency, 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 Development Services Agency, 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.

PLEASE SIGN AND MAIL APPLICATION TO:

Office of Community Assistance, Home Energy Assistance Program
P.O. Box 1240, Columbus, Ohio 43216

X Sign Here _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Application Date _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date Printed – May 2019

Page 6 of 6 n