Energy Assistance Program (EAP)

Energy Assistance Program (EAP) is sponsored by Nevada Division of Welfare and Supportive Services (DWSS). The Energy Assistance Program (EAP) helps qualified Nevada households with the cost of heating and cooling their homes and may assist with past-due utility bills. Eligible households receive an annual, one-time benefit paid directly to their energy provider.

# How to Apply for the Energy Assistance Program (EAP) Submit a completed application (to include the name, date of birth and Social Security Numbers for EVERY PERSON who lives in your home) with the following verification: 1. Proof of identity for the head of household (such as a driver’s license, government issued I. D.

, school I. D. , etc.) and; 2.

Proof of citizenship or legal status if born outside of the United States and; 3. Provide a copy of most recent heating/cooling bills and ; 4. When the utility bill is not in the applicant’s name, provide a written statement from the person listed on the utility bill authorizing the applicant to apply, that includes their address, phone number and signature and; 5.

Proof of ALL income for EVERY PERSON in the household for at least the last thirty Examples of types of income: Employment, child support, social security, Veterans benefits, retirement, public assistance, utility reimbursements, unemployment insurance, interest income, money from family and/or friends, or organizations, educational scholarships and/or grants, etc. Note: If the employed individual is working through an employment agency, provide proof of the last 12 months of earned income.

6. If the household expenses exceed the household income, proof of how the household is meeting their needs. ## **FAILURE TO PROVIDE THIS INFORMATION MAY DELAY THE PROCESSING OF YOUR APPLICATION.

** > Applications are processed in the order in which they are received. Applicants will receive a notice of decision once an eligibility determination has been made. # Please submit your Energy Assistance application and verifications in one of the following ways: Energy Assistance Program Energy Assistance Program 2527 N.

Carson St. , #260 3330 E. Flamingo Rd.

, #55 Carson City, NV 89706 Las Vegas, NV 89121 Fax: (775) 684-0740 Fax: (702) 486-1441 Drop off at either Energy Assistance Program office listed above, or any Intake Site/Welfare office listed on the DWSS Website at Dwss. nv. gov Or email your application to: energyassistance@dwss.

nv. gov Division of Welfare and Supportive Services # ENERGY ASSISTANCE PROGRAM APPLICATION The Energy Assistance Program (EAP) is designed to help eligible Nevada households with their annual heating and electric costs. The total gross monthly income of all household members may not exceed the amounts shown in the chart below.

YOUR HOUSEHOLD’S GROSS MONTHLY INCOME MAY NOT EXCEED: Persons in Home Annual Income Monthly Income Persons in Home Annual Income Monthly Income $23,475 $31,725 $39,975 $48,225 $1,956. 25 $2,643. 75 $3,331.

25 $4,018. 75 $56,475 $64,725 $72,975 $81,225 $4,706. 25 $5,393.

75 $6,081. 25 $6,768. 75 (For families/households with more than 8 persons, add $8,250 to the annual income for each additional person).

Households with a chronic or long-term illness, who pay out of pocket medical expenses and whose gross income exceeds the income guidelines may have their countable income reduced by verified qualifying expenses. Does a household member have a chronic/long-term illness and pay out-of-pocket medical expenses? Yes No (If Yes, and your income exceeds the limits above, please submit verification of your out-of-pocket medical expenses.)

Eligible households receive an annual one-time-per-year benefit called a “fixed annual credit” customarily paid directly to their energy provider(s). The benefit shows as a credit on the bill. Minimum Payment – The minimum yearly payment for eligible households is $360.

 If your family is not currently on the program and you meet the income requirements, apply NOW .  If you received an EAP benefit during the past 12 months, a notice will be mailed to you when it is time to reapply for EAP. Submit a completed application with the required verification .

Suggested income verifications are noted on page B. To get answers to other questions, call: Reno/Carson City (775) 684-0730 Las Vegas (702) 486-1404 Toll Free (800) 992-0900 Visit our website at: http://dwss. nv.

gov for more information on the program requirements. You can find information about the Weatherization Assistance Program at: http://housing. nv.

gov/programs/Weatherization / > (Page A) 2824 – EL (07/25) ## DOCUMENTATION EXAMPLES OF REQUIRED PROOF OF INCOME All documentation sent with your application can be either originals or photocopies. If you are unable to photocopy the originals, our office will copy the material and if requested we will send it back after your case has been processed.

Earned Income : Includes income from employment, self-employment (see below), child care services, house cleaning, and/or any service for which you are paid. Provide copies of check stubs (if paid in cash, a statement from the person who paid you for a service) for at least the last thirty (30) consecutive days. If paid weekly – 4 check stubs; paid bi-weekly or semi-monthly – 2 check stubs.

If you do not have check stubs, a signed and dated statement on letterhead from your employer stating your gross income for the last thirty (30) days and how often you get paid, is acceptable. If working through an employment agency or on-call provide proof of the last 12 months of income.

Self-Employment/Non-Profit Business Income : May include profit and loss statements signed by the applicant detailing gross income and expenses (receipts must be provided for deductions) during the last 12 months, a copy of the sales tax statement showing gross net proceeds, financial statements, a loan application listing income and expenses for the last 12 months, or DWSS Form 2011 that includes receipts for allowable deductions.

Allowable deductions include: cost of goods sold, supplies and materials, advertising, accounting and legal fees, wages paid to employees, office space rent/mortgage, telephone, utilities, transportation costs necessary to produce income, etc. Unearned Income : Includes income from the Social Security Administration, Veterans Administration, pensions, disability, military service, unemployment, child support, alimony, interest, dividends, regular insurance or annuity payments.

If you are receiving Social Security, SSI, Veterans Benefits, pensions, disability income, military income or unemploymen t: provide copies of the benefit verification form or award letter for the current year showing any cost of living raises.

If you are receiving child support/alimony income : provide a copy of divorce decree/separation/settlement agreement, or dated letter from the person paying the support (to include name, address and phone number), or a copy of the last check/statement from the child support enforcement agency .

If you are receiving interest income/dividends : provide 12 months of bank account statements, certificates of deposit or other documentation that contains details and is signed by the financial institution, or a broker’s quarterly statement showing earnings.

Cash Contributions and/ or Recurring Gifts : If someone is helping you pay your expenses or is giving you money: provide a signed statement from each person that includes their name, address, phone number, if the assistance will continue, and the amount provided to you during the last six months.

Provide a signed and dated statement by the person providing the money indicating the amount of support, how often it is paid, when the arrangement began, and whether it is paid directly to a vendor or in cash to you. The statement must include the contributor’s printed name, address(es), and phone number(s).

Student Income : Includes ALL scholarships and grants, e.g., Pell Grant, Federal Supplemental Educational Opportunity Grant (FSEOG), Veterans Administration educational benefits, etc. Please provide written confirmation of the amount of assistance, and the educational institution’s written confirmation of the cost for the prior two (2) semesters and summer school (if applicable) of the student’s tuition, fees, books and equipment.

If benefits are paid directly to the student, copies of the latest benefit checks or canceled checks or receipts for tuition, fees, books, and equipment are acceptable. Public Assistance Income : Includes but is not limited to TANF, county general assistance, Clark County Social Services, or American Indian/Alaska Native General Assistance.

Provide a written statement from the public agency with the amount paid during the last month, or a copy of the award letter or check. PLEASE NOTE: 1099 and W-2 forms by themselves are not acceptable as proof of income.

> (Page B) 2824 – EL (07/25) MAIL, FAX OR DROP OFF YOUR APPLICATION AT EITHER ENERGY ASSISTANCE PROGRAM OFFICE LISTED BELOW OR ANY INTAKE SITE/WELFARE OFFICE LISTED ON THE DWSS WEBSITE OR EMAIL YOUR APPLICATION TO: ENERGYASSISTANCE@DWSS. NV. GOV LAS VEGAS / NORTH LAS VEGAS OFFICE FOR ALL OTHER AREAS 3330 E.

Flamingo Rd. , #55, Las Vegas, NV 89121 2527 N. Carson Street, Suite 260, Carson City, NV 89706 Telephone: (702) 486-1404 Fax: (702) 486-1441 Telephone: (775) 684-0730 Fax: (775) 684-0740 ## APPLICATION FOR ASSISTANCE Please complete every section, and answer each question, and sign the application.

A. APPLICANT/HOUSEHOLD INFORMATION Complete the following for every person living in your home, including yourself (attach an additional page if necessary). The first name on the application should be the applicant (person listed on the utility bill who resides in the home).

Provide proof of identity for the applicant. Ethnicity – Please choose one of the following codes for each household member- H- Hispanic/Latino, N-Non-Hispanic/Latino, or X-Prefer not to disclose.

Race – Please choose one of the following codes for each household member: A-Asian, B-Black or African American; G – North African; H – Middle Eastern; I-American Indian or Alaska Native; J-American Indian or Alaska Native and White; L-Asian and White; M-Black or African American and White; N-American Indian or Alaska Native and Black or African American; U-Native Hawaiian or Other Pacific Islander; W-White; Z-2 or more combinations not listed above or X-Prefer not to disclose.

The information below is used to comply with the requirements set forth by NRS 239B. 022-NRS 239B. 026.

Only the Department of Health and Human Services will have access to this information. Your responses will be kept private and secure. The information will not be used for a discriminatory purpose.

Providing this information is voluntary. What sex were you assigned at birth, such as on your original birth certificate? Please choose one of the following codes for each household member: M-Male, F-Female.

How do you describe yourself? Please choose one of the following codes for each household member: M-Male, F-Female, TM-Transgender Man/Trans Male, TW-Transgender Woman/Trans Female, G-Genderqueer/gender non-conforming, D-Different Identity (Please specify), X-Prefer not to disclose. Which of the following best represents your sexual orientation identity?

Please choose one of the following codes for each household member: S-Straight or Heterosexual, G-Gay, L-Lesbian, B-Bisexual, N-Not listed (Please specify), X-Prefer not to disclose. > Name (Last, First, Middle) (Jr., Sr., III) > How do you describe yourself?

> Sexual Orientation Identity Date of Birth (mm/ dd/yy) Age > U.S. Citizen or Eligible *Non - > Disabled Yes No Social Security Number PLEASE SEE ABOVE FOR CODES *If there are additional people in the home, list them on a separate sheet of paper. *List the names of non-citizen household members authorized as legal residents of the Unites States and provide copies of the front and back of their I-551(Resident Alien Card).

Home Address (include apartment or unit number) City State Zip Mailing Address (If different from your home address.) City State Zip Day/Message/Cell Phone ( ) What is your Primary Language for communication? _________________________________________________ > (Page 1of 7)2824 – EL (07/25) 1.

Dwelling Type: House Apartment Condo/Townhome Rent Room Mobile Home Duplex Motel/Hotel Studio Travel Trailer Other: 2. Dwelling Cost: Rent $ Subsidized Rent $ Space Rent $ Buy $ Own When did you pay off your mortgage? 3.

Rent/Buyers only: Landlord, Project/Complex, Mortgage Company Name: Address: Telephone No.: ( )4. Do you reside in subsidized housing where heating and electric are included in the rent? YES NO IF YES, select all that apply: Section 8 Section 42 Other: C.

HELP US BETTER SERVE OTHERS How did you hear about the Energy Assistance Program?

Check one that most applies: TV Friend Previous EAP Participant Other: Please identify Radio Landlord Received Notice in Mail Print Media Utility Company (flyer or employee) Social Service Employee ELECTRIC SERVICE (Attach Copy of Bill) Check one that applies: Receive bill from utility company Electric service included in rent/mortgage Pay separate bill to landlord for electric service HEATING SERVICE (Attach Copy of Bill) Check one that applies: Receive bill from heating company Heating service included in rent/mortgage Pay separate bill to landlord for heating service > (Electric Company Name) (Heating Company Name) > (Electric Account Number) (Heating Account Number) Is the person listed on the account your landlord?

YES NO (If the account holder does not live with you provide their address, telephone number, relationship to you, proof of identity for the person who is named on the utility bill, and a statement authorizing you to apply for benefits on their behalf.) Is the person listed on the account your landlord?

YES NO (If the account holder does not live with you provide their address, telephone number, relationship to you, proof of identity for the person who is named on the utility bill, and a statement authorizing you to apply for benefits on their behalf.) ARREARAGE ASSISTANCE (Once every five years) ARREARAGE ASSISTANCE (Once every five years) Do you have past due charges with your electric utility and want assistance to pay this debt?

YES NO Do you have past due charges with your heating utility and want assistance to pay this debt? YES NO > (Page 2of 7)2824 – EL (07/25) E. HOW DO YOU WANT YOUR EAP BENEFIT PAID?

Choose how you want your EAP benefits paid : (Mark ONLY One) Split my benefit between my Pay my entire benefit. Pay my entire benefit electric and heating provider. to my heating provider.

to my electric provider. If you choose a split payment your benefit will be split between both of your energy providers not to exceed your annual usage per provider. The benefit may not be an equal 50/50 split.

If you choose a single payment your benefit will be paid to cover your annual usage for that provider, and if there is a remaining balance, it will be paid to your second provider. If you do not choose one of the options above, your benefit will be split between both providers not to exceed the annual usage per provider. 1.

EARNED INCOME : Does any member of the household, regardless of age, work?

YES NO If YES , complete the information below: (Include self-employment, business, child care, housecleaning, odd jobs, temp agencies, and non-profit organization income) > NAME OF PERSON WORKING EMPLOYER DATE OF HIRE List all household members, age 18 or older, who are not currently employed: > NAME OF PERSON FORMER EMPLOYER DATE LAST WORKED > DO YOU EXPECT RE-EMPLOYMENT or PENDING SSI? If YES, explain.

Attach copies of all check stubs or other proof of gross income for at least the last thirty (30) days even if the person is no longer employed. 1099s and W-2s by themselves are not acceptable proof of income. EXCEPTION: Self-employment requires 12 months profit and loss statements.

> (Page 3of 7)2824 – EL (07/25) 2. UNEARNED INCOME : Complete the following, indicating who, if anyone, receives money or benefits from the sources listed below. You must mark YES or NO for each income type and attach proof of all unearned income.

1099s and W-2s by themselves are not acceptable proof of income. > YES NO INCOME TYPE RECEIVING AMOUNT FREQUENCY Boarders / Roomers (Attach notarized proof of rental or lease) Contribution / Gifts / Church or Charitable Donations Educational Assistance / Student Loans > (Attach proof of tuition, books and supplies for prior TWO semesters) Food Assistance (Supplemental Nutrition Assistance Program- SNAP) In Nevada?

Yes No If No, which State?

County Assistance / General Assistance Interest / Dividends / Annuities / Royalties Lump Sum Payments (Settlements / Back Pay, etc.) Military Income / Allotment Room Rental (Attach notarized proof of rental or lease) Social Security Benefits (RSDI) Supplemental Security Income (SSI) Supported Living Arrangement (SLA) Tribal Assistance / Indian General Assistance (IGA) Trust Income (Provide proof if it is not accessible) Utility Allowance / Rebate Check Worker’s Compensation or Temporary Disability 1.

If the household expenses (e.g. rent, utilities, food, etc.) are more than your household’s income, explain how you are able to meet these expenses. 2. If someone is helping you meet your expenses or is giving you money, you must provide a signed statement from each person that includes their name, address, telephone number and amount of help they provided to you during each of the last six months.

Below, fill out the information of the person(s) who provided you a statement: Name of Person Assisting Address Phone Number Amount How often Do you expect any changes in the household’s income or benefits? YES NO If YES, what? When?

Changes in income prior to certification will be used to determine eligibility. > (Page 4of 7)2824 – EL (07/25) Information provided in this application is subject to verification and investigation by federal, state, and local officials.

If you make a false or misleading statement, misrepresent, conceal, or withhold facts, or fail to report changes to establish or maintain eligibility for energy assistance your benefits may be denied, terminated, or reduced. You are responsible for repayment of all monies, services, and benefits for which you were not entitled.

Additionally, you may also be barred from program participation, criminally prosecuted and/or otherwise penalized according to state and federal law. Have you ever been determined to have committed an Intentional Program Violation (IPV)? YES NO If YES, in what State?

______ Initial: I have read the information in section G. Responsibility By signing this application, I am authorizing the Department of Health and Human Services to make any investigation concerning me or any other member of my household which is necessary to determine eligibility for benefits received or to be received under programs administered by the Division of Welfare and Supportive Services.

I hereby authorize and consent to the release of any and all information concerning me and/or my household members to the Division of Welfare and Supportive Services/ Department of Health and Human Services by the holder of the information regardless of the manner or form held, including by, without limitation, wage information, information made confidential by law or otherwise privileged under NRS 422A.

342 or any other provision of law or otherwise. I authorize the Energy Assistance Program to release information about my household, to include energy usage information, to the State of Nevada Housing Division, Weatherization Assistance Program, for potential eligibility in weatherizing my residence. I hereby release the holder of such information from liability, if any, resulting from the disclosure of the required information.

I ACKNOWLEDGE THAT A REPRODUCED COPY OF THIS AUTHORIZATION LEGALLY CONSTITUTES AN ORIGINAL COPY. If I am 60 years of age or older, I hereby consent to the disclosure of my identity and waive my rights as an older person to have my identity kept confidential. I hereby release the holder of information from liability, if any, resulting from the disclosure of the required information.

I consent that the Division of Welfare and Supportive Services or its representatives may survey my energy advise providers of assistance grants, and status at the time of certification.

I consent that the Division of Welfare and Supportive Services use Social Security Numbers (SSNs) provided in this application to verify factors of Energy Assistance Program eligibility, which may include automated data exchange with the Social Security Administration. I agree to notify the Energy Assistance Program of any changes in my household circumstances that may affect my energy assistance benefits.

I understand failure to report changes may cause an overpayment which I would be responsible to pay back and could even be prosecuted by a court of law. I swear I have honestly reported the citizenship of myself and anyone I am applying for. Initial: I have read the information in section H.

Authorization I. RIGHTS AND OBLIGATIONS You have the following RIGHTS: No person will be discriminated against for any reason, e.g., race, age, color, religion, sex, disability, handicap (including AIDS and AIDS related conditions), political belief or national origin, in any program administered by the Division of Welfare and Supportive Services.

When the Energy Assistance Program (EAP) pays another agency, institution, or person to provide EAP services to a household, the provider is not permitted to discriminate for any reason.

Violations of discrimination shall be promptly reported to the Energy Assistance Program office, the Division of Welfare and Supportive Services Administrator, 1470 College Parkway, Carson City, Nevada 89706-7924, (775) 684-0500, the U.S. Office for Civil Rights (OCR), Department of Health and Human Services, 50 United Nations Plaza, San Francisco, California 94102, (415) 437-8310, TDD (415) 437-8311 or by calling toll free 1-800-368-1019.

You have the right to a conference if you believe you have been unfairly treated or a mistake has been made concerning your eligibility for assistance. To request a conference, write or call the Energy Assistance Program.

You have the right to a hearing if you are not satisfied with the agency’s action affecting your assistance if you request the hearing, in writing, within ninety (90) days of the agency’s action/decision, unless the sole issue for the agency’s action/decision is one of state or federal law requiring automatic benefit adjustment.

You have the right to a hearing if your application is denied, acted upon erroneously, or not acted upon with reasonable promptness, or if your benefits have been reduced.

You have the right to a mailed notice of decision telling you if you are eligible for program benefits and in what amount, to whom payments will be made, and the approximate payment date(s); or a notice informing you that you are not eligible for program benefits and why.

Program staff are required to: • Inform applicants of the eligibility requirements for the program; • Counsel on required documents; and/or > (Page 5of 7)2824 – EL (07/25) ________________________________________________ ________________________________________________ _________________________________ • Provide assistance to the applicant when needed.

You have the following OBLIGATIONS: Notify the Energy Assistance Program within ten (10) calendar days of any of the following: • Any change in your household income or household size (number of people residing in the household); • If you change utility companies; or • If you move anytime after submitting your application.

Note: Failure to do so may delay processing your application or result in denial of benefits or a reduction in benefits . Respond to any requests for additional information needed to process your application within ten (10) calendar days . It is your responsibility to ensure the requested materials are mailed or faxed early enough to meet the deadline provided to you.

The Energy Assistance Program is not responsible for lost or misdirected mail, or faxes. (Be sure your name and SSN or UPI are on all documents/correspondence.) Cooperate with the Energy Assistance Program in its efforts to secure all information necessary to determine eligibility or benefits.

If you are applying for the Energy Assistance Program you may receive help with your utility bills. But remember, you must keep paying your bills when they are due . If you do not pay them, the company can charge more money for paying late.

The utility company can even turn off your service and you may be required to pay a deposit before they will turn your service on again. If you cannot pay your bill, contact the utility company, and try to make payment arrangements.

Persons found guilty of intentionally violating program rules will be ineligible for program participation for one (1) year for the first violation, two (2) years for the second violation, and permanently barred from the program for the third violation. Initial: I have read the information in section I.

Rights and Obligations I understand if I fail to initial pages 5-6 where indicated on this application, it does not release me or my household members from those requirements / obligations. I understand the questions on this application and the penalty for hiding or giving false information. I certify under penalty of perjury; my answers are correct and complete to the best of my knowledge and ability.

I swear I have honestly reported the citizenship of myself and anyone I am applying for. I understand the Rights and Obligations as an applicant for the Energy Assistance Program .

Signature of Applicant: Date: Print Name of Other Adult Member(s) in Household: Signature of Other Adult Member(s) in Household: Date: Print Name of Other Adult Member(s) in Household: Signature of Other Adult Member(s) in Household: Date: WITNESS: (Use if applicant cannot read or write or is visually impaired.) I have assisted with the completion of this application for Energy Assistance Program.

The information in this application has been read to the applicant and I have witnessed the above signature. Signature of Witness Date > (Page 6of 7)2824 – EL (07/25) ## IF YOU ARE NOT REGISTERED TO VOTE WHERE YOU LIVE NOW, WOULD YOU LIKE TO REGISTER TO VOTE HERE TODAY? If you do not check either box, you will be considered to have decided not to register to vote at this time.

The NATIONAL VOTER REGISTRATION ACT provides you with the opportunity to register to vote at this location. If you would like help in filling out a voter registration application form, we will help you. The decision whether to seek or accept help is yours.

You may fill out the application form in private. IMPORTANT NOTICE : Applying to register or declining to register to vote WILL NOT AFFECT the amount of assistance you will be provided by this agency. CONFIDENTIALITY : Whether you decide to register to vote or not, your decision will remain confidential.

IF YOU BELIEVE SOMEONE HAS INTERFERED with your right to register or to decline to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Office of the Secretary of State, Capitol Complex, Carson City, Nevada 89710.