GMG - GAP Application

Gas Affordability Program Application

Offered by Greater Minnesota Gas. Administered by the Energy CENTS Coalition
Name*

First NameLast Name
Greater Minnesota Gas Account Number*
Your account number is located on your GMG bill. If you do not know your account number, please call GMG at 888-931-3411.
Is your gas currently disconnected?

YesNo
Did you receive a grant from the Low Income Home Energy Assistance Program (LIHEAP) since October 1, 2023?*

YesNo
STOP

You do not qualify for the GAP Program at this time.

You must receive a grant from the Energy Assistance Program (LIHEAP) in order to participate in GMG's Affordability Program. Click on the link below for more information on the Energy Assistance program in Minnesota.

https://mn.gov/commerce/consumers/consumer-assistance/energy-assistance/

How many people live in your household?*
How many people in your household have income?*
Income Sources (Check all that apply)*

Gross WagesSocial Security Benefits (SSA, SSDI,SDI)Supplemental Security Benefits (SSI)MN Family Investment Program (MFIP)General Assistance (GA)Diversionary Work (DWP)Veterans' BenefitsWorkers' CompensationUnemployment CompensationRetirement IncomePensionLong/Short term DisabilityAlimony/Spousal SupportSelf EmploymentNo Income right nowOngoing financial support from family and/or friendsChild Support (Not counted as income)Other
Enter total MONTHLY Gross Wages for all household members. (We do not include wages for K-12 students)*
Enter total MONTHLY Net income from Social Security benefits for all household members: (SSA/SSDI/RSDI,SSDI)*
Enter total MONTHLY Net income from Supplemental Security benefits (SSI) for all household members: *
Enter total MONTHLY income from MFIP (Minnesota Family Investment Program) for all household members: *
Enter total MONTHLY income from General Assistance for all household members: *
Enter total MONTHLY income from Diversionary Work Program for all household members: *
Enter total MONTHLY income from Veterans' Benefits for all household members: *
Enter total MONTHLY Gross income from Workers' Compensation for all household members: *
Enter total MONTHLY Gross income from Unemployment Compensation for all household members: (Do NOT include additional $600 Federal Assistance from CARES Act) *
Enter total MONTHLY Gross income from Retirement Income (Not Social Security) for all household members: *
Enter total MONTHLY Gross income from Pension (Not Social Security) for all household members: *
Enter total MONTHLY Gross income from Long Term or Short Term Disability for all household members: *
Enter total MONTHLY Gross income from Alimony or Spousal Support for all household members: *
Enter total MONTHLY Gross income from Ongoing support from family or friends for all household members: *
Self Employment: Add lines 3 + 4 + 5 and 6 on your 2022 IRS 1040 - Schedule 1 tax form. If you did not file as self employed on your last return or if you did not file a return, enter your estimated net income from self employment for the year (Annually)*
If you have No Income, write a brief description of how you pay your monthly bills (mortgage/rent, food, utilities..)*
Please enter what your "other income" is in the space provided above, and enter total MONTHLY Gross income from that income source.*

By signing this document, I am applying for the Gas Affordability Program and agreeing to the following:
- I have received Energy Assistance this heating season from the Low Income Home Energy Assistance Program (LIHEAP).
- I agree to allow Greater Minnesota Gas to use payment information to evaluate the program.
- I agree to allow the Energy CENTS Coalition to obtain necessary account information from Greater Minnesota Gas, including LIHEAP status, to process my GAP application.
- I agree to allow GMG to share my information with the Energy CENTS Coalition and the Center for Energy and Environment and I allow them to contact me about GMG's conservation programs.
- I understand that I must make my monthly bill payment in order to stay in the program, to receive credit toward past due amounts and to prevent service disconnection.
- I understand that enrollment in the program is based on a first-come basis and if the program cap is reached before I apply, I may not be enrolled in the Gas Affordability Program.
Signature*

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