Clean Slate Program

Clean Slate Program is sponsored by Ameren Missouri. Helps clear past-due balances for eligible gas customers in Missouri to help them start fresh. This program is not available for Illinois customers.

Clean Slate Application for Assistance 1. Fill out the application below. For each section, read the instructions carefully, answer every question and gather the required documents (extra papers) you need to turn in with your application.

If your application is not complete, it may be delayed or denied. You will have ten days from the date of application to supply any missing documentation. 2.

Take or send your completed application to the agency that processes applications in the county where you live. Visit AmerenMissouri. com/EnergyAssistance for a list of participating agencies.

3. The agency will review your application and the documents you provided, and will contact you with the amount of assistance you’ll receive. HAVE YOU APPLIED FOR LIHEAP THIS PROGRAM YEAR?

Yes No NAME STREET ADDRESS APARTMENT/UNIT NUMBER (if applicable) CITY, STATE, ZIP CODE PHONE NUMBER SOCIAL SECURITY NUMBER (provide all 9 digits) GENDER Female Male I wish not to answer DATE OF BIRTH EMPLOYMENT STATUS (check one) Employed Unemployed Retired HOUSEHOLD SIZE (indicate the number of adults and minors permanently living in your home) How do you heat your home?

(Check one) Electric Natural Gas Alternative Source – 1/12th of balance due for down payment (can be pledge or customer payment) – Must pay by due date each month – You will be enrolled in a Budget Billing payment agreement – You will receive a monthly bill credit for 24 months – Your past due balance will be forgiven over 12 months – Two consecutive missed payments will remove you from the program CLEAN SLATE AGREEMENT (Initial Each) 1/10th of past due amount down payment (or receive pledge) You must have an active Ameren account or be ready for service to be turned on Review the consent statement before signing in black or blue ink.

CONSENT STATEMENT: I declare that the information I have given is true, correct, and complete to the best of my knowledge. I realize that the information which I have given on this application will need to be verified by the agency processing this application. I hereby authorize the agency processing this application to release information relating to my application to my fuel supplier to determine if I am eligible.

I understand that I may be fined, imprisoned, or both under state and federal law if I make false statements on this application to get assistance that I am not eligible to receive. ADDITIONAL AMEREN PROGRAMS: Do you have an Ameren online account? Yes No Create one at: AmerenMissouri.

com Download the Ameren app from the app store on your mobile device. Are you enrolled in paperless billing (check one) Yes No Do you wish to choose the date your bill is due each month? Yes No (Pick A Due Date) AmerenMissouri.

com/PickADueDate Have you received Weatherization Assistance within the last 15 years? (Check one) Yes No I’m not sure Are you registered for text alerts? Yes No Text REG to AMEREN (263736) Are you registered for email alerts?

Yes No Please register at AmerenMissouri. com/Alerts DATE AGENCY USE ONLY: 1) Program: Keeping Current Keeping Cool Clean Slate NOTE: The applicant may participate in Clean Slate and Keeping Current or Keeping Cool; but not Keeping Current and Keeping Cool at the same time . 2) Did you verify income documentation?

Yes No* NOTE: If no, the applicant must provide income documentation for all household members before their eligibility can be determined. 3) Applicant’s Total Monthly Household Income: 4) Poverty Level: 0-150% FPL 151-300% FPL over 301% FPL NOTE: If the applicant’s income is over 301% FPL, they do not meet the income requirements and are ineligible.

If the applicant is under 200% FPL, it is recommended that they also apply for LIHEAP and Weatherization assistance. 5) Referral to Weatherization Agency (if applicable) Yes No Poverty Level Chart by Household Size and Monthly Income Clean Slate/Keeping Current/Cool ing 6) Provide the applicant a copy of the Program Information Flyer regarding Keeping Current, Keeping Cool, Clean Slate, Pick A Due Date, Weatherization and LIHEAP.

• Community Action Agency of STL County • Delta Area Economic Opportunity Corporation • East Missouri Action Agency • Community Action Partnership of North Central Missouri • Jefferson-Franklin Community Action Corporation • Missouri Ozarks Community Action, Inc. • People’s Community Action Corporation • St.

Patrick Center • North East Community Action Corporation • Community Action Partnership of North East MO • Good Samaritan Center • West Central Missouri Community Action Agency • Salvation Army (STL City, STL County, Arnold, and St.

Charles locations) • Urban League (STL City and North STL County) • Samaritan Center *Heating Participants Monthly Bill Credit *Non-Electric Heating Participant’s Monthly Bill Credit HOUSEHOLD SIZE UP TO 300%FPL