ENERGY ASSISTANCE PROGRAMS APPLICATION JULY 2022 – MAY 2023

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 beneft 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 effciency of your home to help lower your energy bills, the
Home Weatherization Assistance Program (HWAP) or Electric Partnership Program (EPP) can help. For HWAP and EPP visit
energyhelp.ohio.gov to fnd 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 or apply online, it can take up to 12 weeks to process.

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 verifcation (if applicable)
previous 30 days or 12 months
A household is defned 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 benefts, its primary heat source must be:
• A regulated or unregulated utility (gas and electric) • A legal freplace (wood)
• A permanent, free-standing fuel tank (oil and 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.
If eligible, the HEAP beneft amount will depend on federal funding levels, how many people live with you, total household
income and the main fuel used. In most cases, benefts are applied directly to the heating bill by the utility company. If you
are reverifying your PIPP amount, it will be based on either 10% or 5% 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)

JULY 2022 – MAY 2023 Income Guidelines

Size of Household Total Gross Annual Household Income
1 up to $20,385 $23,728.50 $27,180
2 up to $27,465 $32,042.50 $36,620
3 up to $34,545 $40,302.50 $46,060
4 (150%) up to $41,625 (175%) $48,562.50 (200%) $55,500
5 (For PIPP, EPP) up to $48,705 (For HEAP, $56,822.50 (For HWAP) $64,940
6 up to $55,785 WCP and SCP) $65,082.50 $74,380
7 up to $62,865 $73,342.50 $83,820
8 up to $69,945 $81,602.50 $93,260
When determining 150% of the federal poverty guidelines, households with more than eight members must add $7,080 to the yearly income or
$581.92 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 $8,260 to the yearly income or $678.90 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 $9,440 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 benefts will be applied to your utility bill starting in January 2023.
If you have questions, please contact your local Energy Assistance Provider 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 (DO NOT SEND ORIGINAL DOCUMENTS)
Proof of U.S. Citizenship Proof of Legal Resident/Qualifed Alien
1. Birth Certifcate/Hospital Birth Records 1. Naturalization Papers/Certifcations 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, IR1-9, or I-551 (Form I-151 will not be valid after
3. Indian Census Record August 1, 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. Verifed 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 verifcation 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 classifed 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/Beneft 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 (including active Most recent IRS
military pay). Self-Employment
including deposit Most recent IRS Form 1099 Income and
Completed Form 1099 Expense Form*
Most recent fled Signed and
IRS Form 1040 or and signed Housing Authority dated letter for the previous
Tax Transcript Employment Documentation from supporter 12 months
Verifcation Form* including name,
Most recent IRS Pay Stubs received Most recent fled
address, and IRS Form 1040
Form 1099 within the previous phone number
30 days from and Schedules
the date of the Most recent IRS
application Form 1099
Payment printout/ Seasonal
statement from Employment
issuing agency Verifcation Form*
*All forms marked with an asterisk can be found at energyhelp.ohio.gov

Privacy Act Notice

DISCLOSURE: The disclosure of Social Security Numbers is mandatory to receive HEAP benefts.
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.
 For Offce Use Only

Primary Household Member Personal Information Section* Date Received

Enter the information completely. Do not send originals. PLEASE USE DARK BLUE OR BLACK INK.
Failure to fll out the application completely, provide all the required documentation and sign the Client Number
application (on the last page) will delay the processing of your application.

First Name* M.I. Last Name*

Social Security Number* U.S. Citizen / Legal Resident (Qualifed Alien)* Military Status Date of Birth (MM / DD / YYYY)*

Yes No Active Veteran No Military Service

Disabled* Yes No Gender Female Male Ethnicity Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

Race American Indian/Alaskan Native Asian Native Hawaiian/Other Pacifc 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 Supplemental Nutrition Assistance Program Housing Choice Voucher Women, Infants, and Children (WIC) Number of Household
Benefts Members
(SNAP) / Food Stamps
HUD-VASH Other
Affordable Care Act Subsidy
Permanent Supportive Housing
Child Care Voucher

Family Type Single Parent/Male Non-related Adults with Children Housing Type Own Residence Structure 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?* Yes No Landlord Organization (if you rent)

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*

* Indicates required information in order to process your application.

Page 1 of 6 u
Primary Household Member Income Section*
Failure to fll out the application completely, provide all the required documentation and sign
the application will delay the processing of your application.
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
Social Security Disability Workers’ Compensation odd jobs, Ohio Electronic Child
Insurance (SSDI) Lump Sum Payouts Care, etc.)
Employment Disability Payout (Estate and Trust Settlements /
Pension (Private and VA) Seasonal-employment
Divorce Settlements / Insurance
Strike Beneft (includes teachers,
Payout / Lottery Winnings)
Widow/Widower’s Beneft construction workers, etc.)
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

$ $ $ $ $

Household Members and Income Section

If you have additional household members (anyone living under your roof at the same address), please complete Household
Members and Income Section of the application (this section), on pages 2–4. 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.
Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Yes No Gender Female Male Ethnicity Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

Race American Indian/Alaskan Native Asian Native Hawaiian/ U.S. Citizen / Legal Resident (Qualifed Alien)*
Other Pacifc 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

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
Social Security Disability Workers’ Compensation odd jobs, Ohio Electronic Child
Insurance (SSDI) Lump Sum Payouts Care, etc.)
Employment Disability Payout (Estate and Trust Settlements /
Pension (Private and VA) Seasonal-employment
Divorce Settlements / Insurance
Strike Beneft (includes teachers,
Payout / Lottery Winnings)
Widow/Widower’s Beneft construction workers, etc.)
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 2 of 6 u
Household Members and Income Section – Continued
Fill out the table below for all household members. Use additional section (on page 4) as needed for other household
members with income.
Full Name* Social Security Number* Date of Birth (MM / DD / YYYY)*

Relationship to person applying

Disabled* Yes No Gender Female Male Ethnicity Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

Race American Indian/Alaskan Native Asian Native Hawaiian/ U.S. Citizen / Legal Resident (Qualifed Alien)*
Other Pacifc 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

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
Employment Disability Payout (Estate and Trust Settlements / Seasonal-employment
Pension (Private and VA) Divorce Settlements / Insurance
Strike Beneft (includes teachers,
Payout / Lottery Winnings)
Widow/Widower’s Beneft construction workers, etc.)
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

$ $ $ $ $

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

Relationship to person applying

Disabled* Yes No Gender Female Male Ethnicity Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

Race American Indian/Alaskan Native Asian Native Hawaiian/ U.S. Citizen / Legal Resident (Qualifed Alien)*
Other Pacifc 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

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
Employment Disability Payout (Estate and Trust Settlements / Seasonal-employment
Pension (Private and VA) Divorce Settlements / Insurance
Strike Beneft (includes teachers,
Payout / Lottery Winnings)
Widow/Widower’s Beneft construction workers, etc.)

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 Members and Income Section – Continued
Fill out the table below for additional household members.
Print additional pages, as needed, for other household members with income.

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

Relationship to person applying

Disabled* Yes No Gender Female Male Ethnicity Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

Race American Indian/Alaskan Native Asian Native Hawaiian/ U.S. Citizen / Legal Resident (Qualifed Alien)*
Other Pacifc 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

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
Employment Disability Payout (Estate and Trust Settlements / Seasonal-employment
Pension (Private and VA) Divorce Settlements / Insurance
Strike Beneft (includes teachers,
Payout / Lottery Winnings)
Widow/Widower’s Beneft construction workers, etc.)

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

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

Relationship to person applying

Disabled* Yes No Gender Female Male Ethnicity Hispanic, Latino or Spanish Origins Not Hispanic, Latino or Spanish Origins

Race American Indian/Alaskan Native Asian Native Hawaiian/ U.S. Citizen / Legal Resident (Qualifed Alien)*
Other Pacifc 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

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
Employment Disability Payout (Estate and Trust Settlements / Seasonal-employment
Pension (Private and VA) Divorce Settlements / Insurance
Strike Beneft (includes teachers,
Payout / Lottery Winnings)
Widow/Widower’s Beneft construction workers, etc.)

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 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 minus Total Household Deductions above Total Household Income minus 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? Yes No Shared Meter? 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 Yes No Do you wish to enroll in PIPP and have a Yes No
to reverify on this account? regulated utility provider?

Please provide your electric utility provider information (if not provided above):
Electric Company/Vendor Account Number Costs included in rent? Yes No Shared Meter? 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 2022 – MAY 2023
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 effciency 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-verifed 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 miss three or more consecutive payments, I will receive a notice on my bill and have one billing cycle after the
notice to make up payments or be dropped from PIPP Plus.
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 the PIPP verifcation and anniversary dates are printed on the utility bills each month.
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 beneft 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
Department of Development 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 Department of Development 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 confdentiality
provisions of the Ohio Revised Code which might otherwise prohibit disclosure and agrees to hold the Ohio Department of Taxation, the Ohio Department of Development, 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 Department of Development, and the Director of the Ohio Department of Jobs and Family Services.
I understand that by signing this application, I grant the Ohio Department of Development, or its authorized providers, access to my bank, employment, public assistance, utility company or other records
needed for verifcation and evaluation of services. I further grant Ohio Department of Development, 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 flling 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:

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

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

Date Printed – June 2022

Page 6 of 6 n