EA Program Application

2025-2026 Energy Assistance Application

Puede traducir este formulario con la bandera de idiomas en la esquina derecha.
Thank you for your interest in our Energy Assistance program!

If you have any questions, please contact us at ea@neighborimpact.org or (541) 504-2155.

In addition to completing this form, we will need you to upload copies of the following documents.
- Proof of gross income for all household members over 18 who are not in high school.
- Copy of electric bill
- Copy of gas bill, if applicable
- Proof of identification for all household members over 18, which can include the following:
  - Driver’s License, Passport, Military ID, State ID/Government issued ID, Birth Certificate,
- Social Security Paperwork.
If you receive any of the following types of income, please upload copies of:
- Wages - copies of paycheck stubs for 60 days prior to date on application
- Social Security, SSDI or SSI - current year benefit verification letter
- Pension – payment statement, award letter
- Temporary Assistance for Needy Families (TANF) - award letter
- Alimony or child support - award letter
- Unemployment – benefit verification letter or award summary

REQUIRED APPLICANT DISCLOSURES AND APPROVALS

2025-2026
PART 1: APPLICANT NOTICE, PROGRAM DISCLAIMERS, AND APPLICANT RESPONSIBILITIES, WAIVER & RELEASE Effective 10/01/2024
- I, Applicant, understand that the government energy and weatherization assistance programs are voluntary and my application is subject to a review process to determine my
  household’s eligibility.
- I understand that in order for my household’s application to be considered, I must submit a complete application that provides all required information.
- I understand that I may be required to provide additional information or documentation to determine my household’s eligibility.
- I understand that my household’s application and additional information or documentation materials will all become part of my household’s application (“Application”).
- I understand that determinations on assistance eligibility are made by the state’s Oregon Housing and Community Services (OHCS) department in conjunction with contracted subgrantee
  agencies (“Subgrantees”).
- In the event that my household’s Application is denied, I may be entitled to a review of my Application under applicable Oregon Administrative Rules.
- Upon successful enrollment in the LIHEAP/OEAP programs, I further authorize OHCS and the State of Oregon, including designated subcontractors, and OHCS Subgrantees to release my
  Application and ongoing LIHEAP/OEAP program benefit information held by OHCS (including its subcontractors and OHCS Subgrantees) to the Energy Services Provider (as defined below) for the
  purposes of administering, monitoring, researching, and evaluating LIHEAP/OEAP program delivery and efficiency.
- I declare that the information I provide to complete my Application is true and correct.
- I agree to comply with the government energy and weatherization assistance program requirements for eligible households.
- Should I receive any heating and/or cooling equipment as result of my eligibility to these programs, I agree to hold OHCS, its sub-grantees and/or contractors harmless.
- I agree that I am responsible to return ineligible funds or funds used improperly.
- I authorize and hold harmless OHCS (including its subcontractors and OHCS Subgrantees) to release my Application and ongoing LIHEAP/OEAP program benefit information up and until one
  (1) program year following my participation in the LIHEAP/OEAP programs.
PART 2: APPLICANT NOTICE, WAIVER & RELEASE RELATED TO ENERGY SERVICE PROVIDERS & APPLICANT’S ENERGY SERVICE ACCOUNT INFORMATION
- I understand that the State of Oregon, including OHCS, its designated subcontractors, and Subgrantees, may request information related to my energy services account(s) (“Account”) from my
  energy service provider(s), including utility, fuel supplier, vendor, or other similar entity providing similar services (“Energy Services Provider”), once my household applies for energy assistance
  through one of the energy assistance programs, including but not limited to the Low Income Home Energy Assistance Program (LIHEAP) and Oregon Energy Assistance Program (OEAP).
- I understand that information related to my Account may be requested by the State of Oregon, OHCS, its designated subcontractors, and Subgrantees for the purposes of, including but not
  limited to, determining my household’s energy assistance eligibility, and administering, monitoring, researching, and evaluating the energy assistance programs (all of which as determined by
  OHCS in its sole discretion).
  With my signature,
- I acknowledge that I am the account holder (or the account holder’s authorized agent) for the Energy Services Provider Account(s) identified in this Application..
- I hereby authorize and hold harmless my Energy Services Provider(s) to release and provide any and all information relating to my account, including but not limited to account number,
  account name, service address, billing dates and amounts charged, information related to collections actions, other miscellaneous account charges and information, or other similar account
  data as may be requested by OHCS or its designated subcontractor (hereinafter “Account Information”) to the State of Oregon, OHCS, its designated subcontractors, and Subgrantees. I
  understand and agree, should I receive any heating and/or cooling equipment as a result of any of these programs, I agree to hold OHCS, it’s sub grantees and/or contractors harmless.
- I hereby authorize and hold harmless my Energy Services Provider(s) for such release of my Account Information for up to two (2) energy assistance program years (10/1 to 9/30) prior to my
  Application and for three (3) program years (10/1 to 9/30) after my Application is submitted.
- I hereby authorize and hold harmless the State of Oregon, OHCS, its designated subcontractors, and Subgrantees in the use (as authorized by OHCS in its sole discretion) of my released
  Account Information.
PART 3: APPLICANT SIGNATURE
With my signature I hereby provide the required authorization, approval and acknowledgments to both PART 1 and PART 2 of this ENERGY/WEATHERIZATION ASSISTANCE APPLICATIONREQUIRED
APPLICANT DISCLOSURES AND APPROVALS.
Applicant Signature
Date

MonthDayYear
Date

Supplemental Disclosures

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Self-Employment Verification

2025-2026
If self-employed, please complete this Self-Employment Verification Worksheet Form:

https://neighborimpact.jotform.com/232987316295064

Self-employed refers to owning your own business. It does not refer to informal income, such as mowing lawns for cash or redeeming cans/bottles.
Landlord Verification

2025-2026
Please send this link to your landlord for them to complete. Do not complete this form on their behalf.

https://neighborimpact.jotform.com/232976119107055

Alternatively, please download and print this paper copy of the Landlord Verification form:

https://www.neighborimpact.org/py24-ll-verification-english/
2025-2026 Declaration of Household Income
I certify that the information in the Declaration of Household Income (DHI) stated is true and accurate by signing this form. I am under penalty of criminal prosecution if false information results in assistance for which I am not eligible. I also understand that providing false information herein constitutes the act of fraud.
Signature

2025-2026 Energy Assistance Application
Current Program Eligibility - At this time, NeighborImpact Energy Assistance only has funding provided for Pacific Power and Cascade Natural Gas for seniors and/or individuals with disabilities.

If you need assistance with other utilities or fuel sources, please check back with us often to see if there is funding through the Low-Income Home Energy Assistance Program.
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2025-2026 Energy Assistance Application

Initial Eligibility Verification

2025-2026 Application Form

Household Information

Utility Information

2025-2026 Application Form: Household Members

Information from ALL household members must be provided to process your application.

Household Member 2

Household Member 3

Household Member 4

Household Member 5

Household Member 6

Household Member 7

Household Member 8

Household Member 9

Household Member 10

REQUIRED APPLICANT DISCLOSURES AND APPROVALS

Supplemental Disclosures

Self-Employment Verification

Landlord Verification

2025-2026 Declaration of Household Income

File Uploads

Electric Bill

Gas Bill

Wages

Social Security Card

Social Security, SSDI, or SSI Verification Letter

Proof of Income

Alimony or Child Support

Pension

Unemployment Benefit

Proof of Identification

2025-2026 Energy Assistance Application