HEPIQ Customer Application

Home Efficiency Program Customer Application
It only takes about 3 minutes to complete this important step towards lower energy bills.

By submitting this application, you are applying to receive an Instant Savers Assessment through the Ameren Illinois Home Efficiency Program. Following your submission, a program representative will contact you with more details.

If you have any questions, please call us at 1.866.838.6918.
Section 1: Program Eligibility
Please verify that you meet the basic eligibility requirements of the program:

Applicant must be a residential customer of Ameren Illinois, heating with gas or electricity delivered by Ameren Illinois. Applicant’s Maximum Gross Annual Household Income is at or under the amount listed below.
Section 2: Applicant Information
Primary Account Holder Name *

First Name Last Name
Home Phone *
Cell Phone
Address *
City *
County *
State *
Zip Code *
Email *
Date of Birth *
Gender *

Male Female
Were you referred by a Program Ally? *

Yes No
Name of Program Ally: *
Do you own your home? *

Yes No
Mobile home?
Lot Number
Primary Heat Source *

Gas Electric
Customer Segment
What type of foundation do you have in your home?
Check all that apply *

Basement Crawl space Slab
How many members are in your household (including you)? *
Is your household income at or below $36,420? *

Yes No
Is your household income at or below $49,380? *

Yes No
Is your household income at or below $62,340? *

Yes No
Is your household income at or below $75,300? *

Yes No
Is your household income at or below $88,260? *

Yes No
Is your household income at or below $101,220? *

Yes No
Is your household income at or below $114,180? *

Yes No
Is your household income at or below $127,140? *

Yes No
Is your household income at or below $140,100? *

Yes No
Is your household income at or below $153,060? *

Yes No
Is your household income at or below $166,020? *

Yes No
Is your household income at or below $178,980? *

Yes No
Is your household income at or below $191,940? *

Yes No
Is your household income at or below $204,900? *

Yes No
Section 3: List of Household Members
Household Member #1
Household Member #1 Name *

First Name Last Name
Check all that apply *

Adult Child Veteran Senior Citizen (55+)
Household Member #2
Household Member #2 Name *

First Name Last Name
Check all that apply *

Adult Child Veteran Senior Citizen (55+)
Household Member #3
Household Member #3 Name *

First Name Last Name
Check all that apply *

Adult Child Veteran Senior Citizen (55+)
Household Member #4
Household Member #4 Name *

First Name Last Name
Check all that apply *

Adult Child Veteran Senior Citizen (55+)
Household Member #5
Household Member #5 Name *

First Name Last Name
Check all that apply *

Adult Child Veteran Senior Citizen (55+)
Household Member #6
Household Member #6 Name *

First Name Last Name
Check all that apply *

Adult Child Veteran Senior Citizen (55+)
Household Member #7
Household Member #7 Name *

First Name Last Name
Check all that apply *

Adult Child Veteran Senior Citizen (55+)
Household Member #8
Household Member #8 Name *

First Name Last Name
Check all that apply *

Adult Child Veteran Senior Citizen (55+)
Section 4: Supporting Documents

If using a mobile device or tablet, you can take pictures of your supporting documents and attach them to the submission.
Would you like to submit supporting documents (proof of income and homeownership) at this time? *

Yes No, please follow up with me
1. Proof of Income:

- Please provide pages 1 and 2 of your most recent federal tax return

OR

- If you do not file a tax return, please provide alternative proof of income (social security statement, pension or annuity statement, etc.)

2. Proof of Homeownership

Acceptable documents include one of the following:

- Current real estate tax bill
- Deed, recorded mortgage, land contract or life lease

NOTE: APPLICANTS SHOULD BLACK OUT ALL SOCIAL SECURITY NUMBERS LISTED ON THE DOCUMENTATION.

Questions about the required documents? Contact us at 1.866.838.6918.
Add Files to your Submission *

Add Files
Maximum files that can be attached is 4. If you are using a tablet or mobile device, you can take photos of the documentation and attach them here. Cancel of
Applicant Signature
Applicant Acknowledgement *

By checking this box and signing below, I confirm that all information listed above is true and accurate and completing this application does not guarantee my household will receive incentives. Ameren Illinois may change the program requirements, incentives, or terms and conditions at any time.
Signature *
Should be Empty:

Home Efficiency Program Customer Application

Section 1: Program Eligibility

Section 2: Applicant Information

Section 3: List of Household Members

Section 4: Supporting Documents

Applicant Signature