Income Verification Form
(For Internal Use Only – MEA Grant Eligibility)
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Total Number of People in Household
Total Annual Household Income (before taxes)
Does your household include any of the following? (check all that apply)
Elderly resident(s) (age 65+)
Disabled individual(s)
Child(ren) under age 5
None
Source(s) of Income
Employment
Social Security/Disability
Retirement/Pension
Public Assistance (TANF, SNAP, etc.)
Other
If "other", please specify.
What type of energy source does your home primarily use for heating?
Electricity
Oil
Propane
Natural Gas
Other
Who is your primary utility company?
Pepco Only
Pepco & Oil or Propane
BGE Electric Only
BGE Electric & Gas
SMECO Electric Only
SMECO & Oil or Propane
BGE (Baltimore Gas & Electric)
BGE + Washington Gas
How much on average is your monthly utility bill in the winter?
How much on average is your monthly utility bill in the summer?
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Do you have central AC?
Yes
No
Do you have access to your attic space(s)?
Yes
No
Are there any known health and safety issues in the home? Included but not limited to structural, mold/moisture, pests, knobs & tube wiring, asbestos, or roof leaks?
Yes
No
If yes, please specify.
Are you open to switching your gas/oil heating and appliances to electric?
Yes
No
Do you know the size of your electrical panel?
Yes
No
If yes, please specify.
Are any HVAC/appliances nonfunctional?
Yes
No
If yes, please specify.
Have you participated in a utility or state-funded weatherization program in the past?
Yes
No
What is your preferred method of communication?
Please Select
Phone
Text
Email
Income Documentation (select documentation type)
*
Please Select
Recent pay stubs (last 2 months)
Most recent federal tax return
Social Security / Disability award letter
Unemployment statement
Other official income documentation
Currently unemployed
Upload your documentation here.
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I certify that the information provided above is true and accurate to the best of my knowledge. I understand this information will be used only to determine eligibility for grant-supported programs.
*
Date
*
.
Month
.
Day
Year
Date
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