OPT-IN

OPT-IN

POWER On/Gas Affordability Program
Name*

First NameLast Name
I have received an OPT In Letter*

YESNO
OPT In ID Number from Letter*
Your ID number is listed on your letter
Xcel Energy Account Number
Email
example@example.com
Phone Number
Please enter a valid phone number.
Is your address different from the address on your Opt-In Letter?

YESNo
Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your mailing address different than your service address?

YESNO
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Household Size*
Has your income changed since you applied for Energy Assistance?*

NoYes
Monthly Income for household
Do not include income from child support, food support or earned income from students grades K-12
By signing this document, I am giving Energy CENTS Coalition and Xcel Energy permission to obtain information about me and I am agreeing to the following:
- I agree that I have received Energy Assistance for the current Low Income Home Energy Assistance Program (LIHEAP) federal fiscal year.
- I agree to allow Xcel Energy to use payment information in the evaluation of the program.
- I understand 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 agree to notify Energy CENTS Coalition if there are changes in my income, household size or if I move.
- I understand that enrollment in this program will automatically cancel my Averaged Monthly Payment enrollment or any other previously agreed upon payment plan.
- I agree to allow the Energy CENTS Coalition to share any of the above information with other organizations that provide energy assistance, conservation and other services.
- I agree to allow heating and electricity companies to give data about my account and energy use to the Energy CENTS Coalition for the PowerOn program and any Energy CENTS Coalition conservation programs.
Signature*
Please type name
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