OPT-IN

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

If you have not recieved an OPT-IN enrollment letter with an ID number, please complete an application for the POWER On/Gas Affordability Program by clicking this link.

POWER On/GAS Affordability Program Application

Xcel Energy Account Number

Is Your Service Currently Disconnected?

YesNo

If your electric or gas service with Xcel Energy is currently SHUT OFF:

Complete and Submit this application, then call our office at 651-774-9010 to alert us of your situation.

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

How many people live in your household?*

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

If you now have no income, write a brief description of how you pay your monthly bills each month.*

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