CAPECO
721 SE 3rd, Suite D
Pendleton, OR 97801
541-276-1926 | 800-752-1139

All fields marked with an asterisk (*) are required.

In Order to process your Energy Assistance Application as quickly as possible, the following items are required to be submitted to CAPECO:

• Completed Application
• Copy of Social Security Number card for every household member
• Copy of State or Federal ID for every household member over the age of 18
• Income Verification for every household member over the age of 18 (last 30 days)

Please tell us who is in your household:

Additionally, in order for CAPECO to determine eligibility for this application you will need to provide Social Security Numbers (SSN) for every household member AND a state or federal issued photo identification (ID) for every household member who is 18 years old or older. You may provide the SSNs and upload copies of IDs here or you can mail copies of each of those to us.

• To provide SSNs and photo IDs here, scroll through and read the entire terms and conditions and select the first box, then complete a row for each household member and upload copies of IDs.
• To mail copies of your SSNs and photo IDs, scroll through and read the entire terms and conditions and select the second box, then complete a row for each household member and mail documentation to CAPECO - Energy, 721 SE 3rd St STE D, Pendleton OR 97801.
  

• 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.

With my signature,

• I authorize my household’s Application to be shared by and between OHCS and the State of Oregon, including designated subcontractors, and Subgrantees for the purposes of determining eligibility, and administering, monitoring, researching, and evaluating (all of which as determined by OHCS’ in its sole discretion) the government energy and weatherization assistance programs.
• 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.
• I agree that I am responsible to return ineligible funds or funds used improperly.

• 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 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.

With my signature, I hereby provide the required authorization, approval and acknowledgments to both PART 1 and PART 2 of this ENERGY/WEATHERIZATION ASSISTANCE APPLICATION- REQUIRED APPLICANT DISCLOSURES AND APPROVALS.