Energy Savings Program

Income Information
How many people live in your household?*
How many people in your household have income?*
Income Sources (Check all that apply)*

Gross WagesSocial Security Benefits (SSA, SSDI,SDI)Supplemental Security Benefits (SSI)MN Family Investment Program (MFIP)General Assistance (GA)Diversionary Work (DWP)Veterans' BenefitsWorkers' CompensationUnemployment CompensationRetirement IncomePensionLong/Short term DisabilityAlimony/Spousal SupportSelf EmploymentNo Income right nowOngoing financial support from family and/or friendsChild Support (Not counted as income)Other
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 (Not Social Security) 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 2024 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)*
If you have No Income, write a brief description of how you pay your monthly bills (mortgage/rent, food, utilities..)*
Please enter what your "other income" is in the space provided above, and enter total MONTHLY Gross income from that income source.*
Did you receive a grant from the Low Income Home Energy Assistance Program (LIHEAP) in the last 12 months?*

YesNo
If you did not receive a grant from the Energy Assistance Program in the last 12 months, you must provide proof of your income. Click on Browse Files to attach your income information. (Copy of federal tax return, copies of pay stubs for one month's earnings, proof of public assistance or Social Security payments, etc.)

Browse Files
If you are unable to attach your proof of income, you can mail your proof of to us at: Energy CENTS Coalition; 823 East 7th St, St Paul, MN 55106 Cancelof

Terms and Conditions
By signing this document, I am signing up for the Energy Savings Program. I also agree to allow the Energy CENTS Coalition to obtain information from Xcel Energy and from other heating utility accounts and share that information with other organizations that provide energy conservation and other relevant services. I verify that all information on this application is, to the best of my knowledge, correct.
Signature*

Clear
Date

MonthDayYear
Date
Should be Empty:

Energy Savings Program

Household and Property Information

Income Information

Heating and Appliance Information

Terms and Conditions