EmPower

APPLICATION
EmPower
EmPower+ provides incentives to low- and moderate-income households for energy improvements. This application will determine the incentives you qualify for based on your household income.

The information in the following application will help determine which services and programs are most appropriate for you. In some situations, services to low-income households are provided by agencies of the Weatherization Assistance Program (WAP In these instances, this application will serve as an application for the WAP and may be forwarded to your local agency for these services. Please print clearly and provide as much information as possible. This application can be

completed online at nyserda.ny.gov/empower-apply. Completing the application online is the fastest way for NYSERDA to

review and approve your application.

This checklist will help ensure that your application will be processed in a timely manner. Please place a  in the appropriate box once you have ensured that all Application Sections are complete, and the required documentation is provided. Applications are processed on a first come, first served basis.
RENTERS ONLY:
UTILITY INFORMATION (SECTION D):
INCOME INFORMATION (SECTION F & G):
DEMOGRAPHICS (SECTION H): Optional
APPLICANT AFFIRMATION (SECTION I)

General Applicant Information Sections A, B & C – Verify that all required fields are completed unless marked as “optionalLandlord Name, Address and Phone Number provided in Section CSigned Customer Fuel/Energy Bill Release AuthorizationInclude a copy of complete Electric BillInclude a copy of complete Gas Utility Bill or bill from Fuel Supplier if heating by propane, oil, kerosene, wood, or coalVerify that all required fields are completeOptionalRead and sign
HELPFUL PROGRAM LINKS:
- nyserda.ny.gov/empower
- nyserda.ny.gov/empower-apply
- To find an Empower+ participating contractor, please visit nyserda.ny.gov/Contractors/Find-a-Contractor/Empower-
- For additional information and assistance, please contact a Region Clean Energy Hub at nyserda.ny.gov/All-Programs/
- nyserda.ny.gov/empower-income
PLEASE RETURN APPLICATION TO:
TRC Companies 3 Corporate Drive, Suite 202 Clifton Park, NY 12065
EmPower+ provides incentives to low- and moderate-income households for energy improvements. This application will determine the incentives you qualify for based on your household income.
SECTION A: APPLICANT INFORMATION
Applicant Name
Address
Apartment
CITY
ZIP
City
State Zip
County
Secondary Phone (include area code)
Email Address (Required)
Email Address (Required)
example@example.com
Mailing Address (if different from above)
Relationship to Applicant
Phone Number (include area code)
SECTION B: DWELLING INFORMATION

# of units Manufactured/mobile home Group home/shelterI rent and utilities are included in rental fee
Multifamily
# of units Manufactured/mobile home Group home/shelter

I ownI rent and pay my utilities directlySingle-FamilyMultifamily
SECTION C: OWNER INFORMATION
Owner’s Name
Owner’s Name

Is the Owner’s Address the same as the building address? Yes No – If “No” please complete the address below.Phone Number (include area code)
Owner’s Name
Phone Number (include area code)
Address
OPTIONAL: Please add any information that we may find helpful in reducing your energy consumption and list occupant health issues or special needs we need to be aware of
REFERRING AGENCIES AND EMPOWER+ CONTRACTORS: Print your business or agency name.
Electric

ElectricOil Kerosene Natural Gas Propane WoodMy main heating fuel is:Pellets I don’t knowSECTION D: UTILITY INFORMATIONOil Kerosene Natural Gas Propane WoodOil Kerosene Natural Gas Propane WoodPellets I don’t knowOther
Electric

ElectricOil Kerosene Propane Wood PelletsMy secondary heating fuel is:Coal I do not have secondary fuelOil Kerosene Propane Wood PelletsOil Kerosene Propane Wood PelletsOil Kerosene Propane Wood PelletsCoal I do not have secondary fuelOther
ELECTRIC UTILITY: If you are responsible for the electric bill, provide the following:
Utility Name
If NYSEG or RG&E – POD
GAS UTILITY: If you are a natural gas utility customer and responsible for the bill, provide the following:
Utility Name
If NYSEG or RG&E – POD
If NYSEG or RG&E – POD
PRIMARY FUEL SUPPLIER: if you heat by a fuel other than natural gas or electricity, provide the following:
Company Name
SECTION E: PARTNER INFORMATION
If you would like to work with a specific participating program contractor in NYSERDA’s energy efficiency programs, please indicate below. We will work to accommodate your request, but final selection is based on the participating program contractor’s availability and acceptance of your project. If you are not working with a program contractor, we will assign the next available participating program contractor from our approved list or you can select from one of our participating

contractors at nyserda.ny.gov/Contractors/Find-a-Contractor/Empower-Plus-Contractors.
Contractor Name
NYSERDA supports a network of professional energy advisors who may already be assisting you with this program, other NYSERDA programs, utility offerings, and other local resources. If you are currently working with a NYSERDA Clean Energy Hub, please indicate which one below. The program will share limited project information with them so they can continue to

assist you each step of the way. A list of Hubs can be found at nyserda.ny.gov/All-Programs/Regional-Clean-Energy-Hubs.
Clean Energy Hub Name and/or Organization
SECTION F: INCOME DOCUMENTATION - Please select one of the following
Referral letter: If you received a letter from NYSERDA with a referral code, enter it below. If you have a referral code,

A.
no additional income documentation is required.
Referral Code#
Provide a copy of ONE of the following: Copy of entire award letter for HEAP, SNAP (Food Stamps), TANF (Temporary
Assistance for Needy Families or Supplemental Security Income dated within the past 12 months. No additional income documentation is required.

B.C. If A, or B above do not apply, then provide income documentation under one of the options below:
C. If A, or B above do not apply, then provide income documentation under one of the options below:
- Option 1
- - Weekly: multiply weekly income representing 4 most recent weeks by 4.3 - Bi-weekly: multiply 2 most recent consecutive weeks by 2.15 - Twice a month: multiply by 2 • Social Security and/or Social Security Disability: copy of award letter • Documentation of all forms of income. This can include disability, worker’s compensation, unemployment, pension, maintenance, annuities, Veteran’s benefits, and all other income • Self-Employment: IRS Report of quarterly earnings for the last three months Option 2 • Tax returns: This option is only available if all household members who were required to file a tax return did so. If documenting income with tax returns, all sources of income must be documented with tax returns. Returns must be the most recent Federal Income Tax Return (Form 1040, 1040A, or 1040EZ If documenting rental, business or farm income – you must submit corresponding schedules (Schedule C, E, and F
SECTION G: INCOME INFORMATION
Total number of members in the household?
If applying using option A or B from above, only fill in Full name, gender, age, and student. If you selected option C, complete the full table.

Include the following information for each household member. For gender please use the following: 1. Self-identified Male, 2. Self-Identified Female, 3. Other

	Full Name	Gender	Age	Student (Yes or No)	Source(s) of Income	Weekly	Monthly	Yearly
1
2
3
4
5
6
7
8
9

Total Income for the Household
Total Income for the Household
Total Income for the Household
SECTION H: DEMOGRAPHICS
To assist NYSERDA in understanding the impacts of our programs on local communities, please complete the below demographic questions. Answering these questions is optional and does not affect your program eligibility.

Indicate the number of household members who are:
60 years of age or older
Disabled
17 years of age or younger
Past/current military service members
Indicate if the applicant is: (select at least one, and as many as applicable)

Prefer Not to AnswerNative Hawaiian or Pacific IslanderNative American / First Nation / Alaskan NativeWhiteAsianUnknownBlack or African AmericanOther
Indicate if the applicant is

Hispanic, Latino, or Spanish OriginsUnknownNot Hispanic, Latino, or Spanish OriginsPrefer Not to Answer
Indicate how many members of the household are: (select at least one, and as many as applicable)
Number Race
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American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Multi-race (two or more of the above)

Indicate ethnicity of household members including primary applicant:
Number Ethnicity
Hispanic, Latino, or Spanish Origins
Not Hispanic, Latino, or Spanish Origins
SECTION I: APPLICANT AFFIRMATION
I,
authorize the release of my eligibility determination and

information provided on this application, supporting documents including income documentation, as well as information regarding my project status, and project information (including existing household conditions, installed measures, energy savings, and other data) to the following: NYSERDA and its representatives; to the extent my project is receiving federal funding to the Department of Energy and its representatives; the NYS Weatherization Assistance Program (WAP) and/or its designated representatives; any community- based organizations working on behalf of NYSERDA programs; my electric and natural gas utilities; and the following individuals or
organizations
I have engaged for the purpose of assisting me with the completion and submittal of the application.

Participant agrees and authorizes the sharing of the participant-customer’s information and/or project-level information with New York State Department of Public Service Staff and appropriate local utility, including its agents or authorized representatives, in carrying out its responsibilities under New York State Public Service Commission orders. (For clarity, the term project level includes the information based on the scope of the project, including, but not limited to, whole building, building or subsets of the project

I understand that the information provided by me may be used to contact or assist me to utilize any current or future program offerings I may be eligible for and for the purposes of determining eligibility for NYSERDA and/or utility residential programs and financial incentives, determining eligibility for the NYS WAP, for estimating energy savings potential, and for evaluation purposes. I understand that all information will be kept confidential to the extent permitted by law. I understand that if services are provided to me through NYSERDA’s residential programs or the NYS WAP, that my participation in these programs will not affect my social security, public assistance, or any other income.

I understand that this application does not guarantee that assistance will be granted to me. Whether or not services are provided will depend on the number of applications received and the availability of funds and priorities established by the programs.

I agree to provide NYSERDA representatives, the NYS WAP representatives, and independent participating contractors access to my dwelling, at times that are mutually acceptable, to perform program activities including energy inspections, installation of measures, Quality Assurance, and evaluation activities. I understand that participating contractors are independent contractors and provide a one-year warranty on labor for work completed. I further understand that participating contractors and vendors will provide appropriate warranties on any equipment provided and that no additional warranties are provided by NYSERDA or the NYS WAP.

I subscribe and affirm, under the penalties of law, that the statements made on all parts of this application, including statements made on any accompanying documents, have been examined by me and are to the best of my knowledge true and complete.

I understand that my signature on this form gives permission for NYSERDA, representatives of the NYS WAP, and their designees to assure my eligibility for NYSERDA’s programs and the NYS WAP. I consent to any inquiry to verify or confirm the information that I have given. I understand that if I give false information or withhold information in order to receive benefits that I am not entitled to,

I can be prosecuted to the fullest extent of the law. I also state that no person named in this application is subject to disqualification for weatherization services under the Immigration Reform and Control Act of 1986 (Public Law 99-063
Applicant Signature

Clear
Applicant Signature

Clear
Date

MonthDayYear
Date
Date

MonthDayYear
Date
Applicant Representative Signature
Your contact information may be shared with other residential programs within NYSERDA. To opt out of this, please initial here
Reviewed By: HEAP OFA Utility Weatherization Subgrantee EmPower Other

INTERNAL USE ONLYReviewed By: HEAP OFA Utility Weatherization Subgrantee EmPower OtherReviewed By: HEAP OFA Utility Weatherization Subgrantee EmPower OtherReviewed By: HEAP OFA Utility Weatherization Subgrantee EmPower OtherReviewed By: HEAP OFA Utility Weatherization Subgrantee EmPower OtherReviewed By: HEAP OFA Utility Weatherization Subgrantee EmPower Other
Check all benefits that the household receives: SSI HEAP SNAP TANF

Check all benefits that the household receives: SSI HEAP SNAP TANFCheck all benefits that the household receives: SSI HEAP SNAP TANFCheck all benefits that the household receives: SSI HEAP SNAP TANFCheck all benefits that the household receives: SSI HEAP SNAP TANF
On the basis of the information provided by the applicant, the household is determined to be

Eligible for Moderate-Income OnlyEligible for WeatherizationNOT Eligible for WeatherizationEligible for Low-Income ServicesNOT Eligible for Low-Income ServicesLow-Income eligible, but wait-listed for Weatherization
Check here if

Household was previously served by WeatherizationHousehold ineligible for further services through EmPower
Additional Comments
EmPower+ Representative Signature

Clear
Title
Date

MonthDayYear
Date
Should be Empty:

APPLICATION

EmPower

RENTERS ONLY:

UTILITY INFORMATION (SECTION D):

INCOME INFORMATION (SECTION F & G):

DEMOGRAPHICS (SECTION H): Optional

HELPFUL PROGRAM LINKS:

PLEASE RETURN APPLICATION TO:

SECTION A: APPLICANT INFORMATION

SECTION C: OWNER INFORMATION

SECTION E: PARTNER INFORMATION

SECTION G: INCOME INFORMATION

SECTION H: DEMOGRAPHICS

Number Race

SECTION I: APPLICANT AFFIRMATION