Energy Efficiency Program - Community Care

DTE Energy Efficiency Assistance Program Application

Name (DTE Account Holder)

First Last

DTE Energy Electric Account Number(Required)

DTE Energy Natural Gas Account Number(Required)

DTE Account(Required)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Applicant Name if different from the DTE Account Holder

First Last

Relationship to DTE Account Holder

Community Action Agency (CAA/Nonprofit Organization NPO) Name

CCA/NPO Phone Number

Program Income Eligibility- Qualifying Assistance Programs(Required)

The DTE EEA Program provided services to DTE customers who have low-income to moderate-income DTE customers. Low-Income customers cannot exceed 200% of the Federal Income. Limited funding available to customers within 201%-300% of Federal Poverty Guidelines. Have you or any member of your household received assistance in the last 12 months from any of the qualifying programs noted below?

Number of Adults Living Household, Including Applicant? (18 year or older)

Number of Children Living in Household? (under 18 years of age)

Total Number In Household?

Please upload DTE Bill

Max. file size: 100 MB.

Please upload a picture of your Valid State ID

Max. file size: 100 MB.

Please upload Deed

Max. file size: 100 MB.

only applies to home owners

Please upload Sources of Income

Drop files here or

Max. file size: 100 MB.

Sources of income may include paystubs, social security SSI documents, unemployment letter/MARVIN statement, pension letter, DHS budget letter, child support documentation, etc. Proof of income or qualifying assistance program documentation must be provided to determine EEA Program eligibility and may be requested for review by a DTE Energy Specialist or Representative.

Please upload any documentation that proves Qualifying Asisstance Program enrollment

Max. file size: 100 MB.

The following method was used to determine the customer eligibility:

Total household income is at or below 200% of Federal Poverty Guidelines

Total household income s between 201% and 300% of Federal Poverty Guidelines

Total household income meets the US.S Department of Housing and Urban Development Low Income Limit (at or below 80% of median income)

Customer Certification(Required)

I, the applicant, certify the information provided above is complete, true, and accurate to the best of my knowledge. I hereby grant DTE permission to verify any and all information provided to determine eligibility EEA Program services to my home.

Digital Signature