CAPECO 721 SE 3rd, Suite D Pendleton, OR 97801 541-276-1926 | 800-752-1139
☐ LIHEAP ☐ OEAP Other: ______________ Auth# _____________
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:
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.
- PART 1 -
APPLICANT NOTICE, PROGRAM DISCLAIMERS, AND APPLICANT RESPONSIBILITIES, WAIVER & RELEASE
With my signature,
- PART 2 -
APPLICANT NOTICE, WAIVER & RELEASE RELATED TO ENERGY SERVICE PROVIDERS AND APPLICANT'S ENERGY SERVICE ACCOUNT INFORMATION
- PART 3 -
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.
Intake Signature ____________________________________
Data Entry Signature ____________________________________
Authorizing Agency Signature ____________________________________
☐ APPROVED ☐ DENIED Revised 9/28/2020