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  • Medical Electric Affordability Program Application

    Offered by Xcel Energy and Administered by the Energy CENTS Coalition
  • Please check service(s) provided by Xcel Energy.
  • Is your service currently disconnected?
  • Did you receive a grant from the Low Income Home Energy Assistance Program (LIHEAP) this heating season (October 1 - September 30)
  • Do you have medical equipment or a medical conditions that requires electricity in order to sustain life?
  • Do you have a Critical Life-sustaining Medical Equipment and Emergency Form on file with Xcel Energy? (This form requires certification from medical doctor)

  • STOP 

    Please contact Xcel Energy at 1-866-975-7327 to speak to a personal account representative regarding your necessary medical equipment.  A Critical Life-sustaining medical equipment and emergency form must be on file with Xcel in order to qualify for the Medical Electric Affordability Program.

  • STOP 

    You do not qualify for the Medical Electric Affordability Program.  You must need medical equipment or have a medical condition that requires electricity in order to sustain life.  You may qualify for the POWER On and/or the Gas Affordability Program.  Click the link below to complete that application.

    https://form.jotform.com/72894728277171

     

  • STOP 

    You do not qualify for the Medical Electric Affordability Program.  You must need medical equipment or have a medical condition that requires electricity in order to sustain life.  

     

    We may abe able to assist you with the POWER On/GAP program, but you first need to receive a grant from the Energy Assistance Program (LIHEAP).  Click on the link below for more information on the Energy Assistance program in Minnesota.

    https://mn.gov/commerce/consumers/consumer-assistance/energy-assistance/

     

  • Format: (000) 000-0000.
  • Phone type

  • Format: (000) 000-0000.
  • Phone type

  • Do you Own or Rent*
  • Select the option that best describes your home:*

  • Income Sources (Check all that apply)*

  • Enter total MONTHLY Gross Wages for all household members. (We do not include wages for K-12 students)*
  • Enter total MONTHLY Net income from Social Security benefits for all household members: (SSA/SSDI/RSDI,SSDI)*
  • Enter total MONTHLY Net income from Supplemental Security benefits (SSI) for all household members: *
  • Enter total MONTHLY income from MFIP (Minnesota Family Investment Program) for all household members: *
  • Enter total MONTHLY income from General Assistance for all household members: *
  • Enter total MONTHLY income from Diversionary Work Program for all household members: *
  • Enter total MONTHLY income from Veterans' Benefits for all household members: *
  • Enter total MONTHLY Gross income from Workers' Compensation for all household members: *
  • Enter total MONTHLY Gross income from Unemployment Compensation for all household members: *
  • Enter total MONTHLY Gross income from Retirement Income (Not Social Security) for all household members: *
  • Enter total MONTHLY Gross income from Pension for all household members: *
  • Enter total MONTHLY Gross income from Long Term or Short Term Disability for all household members: *
  • Enter total MONTHLY Gross income from Alimony or Spousal Support for all household members: *
  • Enter total MONTHLY Gross income from Ongoing support from family or friends for all household members: *
  • Self Employment: Add lines 3 + 4 + 5 and 6 on your 2023 IRS 1040 Schedule 1 tax form. If you did not file as self employed on your last return or if you did not file a return, enter your estimated net income from self employment for the year (Annually)*
  • Please enter what your "other income" is in the space provided above, and enter total MONTHLY Gross income from that income source.*
  • Because you did not receive a grant from the Energy Assistance Program, you must provide proof of your income. Please select how you would like to send us your proof.*
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  • Mail your income verification to:

    Energy CENTS Coalition

    823 East 7th St

    St Paul, MN 55106

  • email your income verification to:

     ecc@energycents.org

     

  • By signing this document, I am giving Energy CENTS Coalition and Xcel Energy permission to obtain information about me and I am agreeing to the following:

    • I agree to allow Xcel Energy to use payment information in the evaluation of the program.
    • I agree to allow the Energy CENTS Coalition to obtain account information, including LIHEAP status, from Xcel Energy necessary to process this application.
    • I understand I must make my monthly bill payment in order to stay in the program, to receive credit toward past due amounts and to prevent service disconnection.
    • I understand that enrollment on this program is based on a first come first served basis.
    • I agree to notify Xcel Energy and Energy CENTS Coalition if there are changes in my income, household size or if I move.
    • I understand that enrollment in this program will automatically cancel my Averaged Monthly Payment enrollment or any other previously agreed upon payment plan.
    • I agree to allow the Energy CENTS Coalition to share any of the above information with other organizations that provide energy assistance, conservation and other services.
    • I agree to allow heating and electricity companies to give data about my account and energy use to the Energy CENTS Coalition for the PowerOn program and any Energy CENTS Coalition conservation programs.
    • I understand that I must have a certified medical form on file with Xcel Energy in order to be eligible for this program.
  • Date
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    2 digit month, 2 digit day, 4 digit year
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