Winter Shut Off Protection and Payment Plan

Winter Shut-off Protection & Payment Plan Application

For assistance with this form, please call 616-355-1500 or visit our Service Center (625 Hastings Ave) during office hours.
To qualify for the Winter Shut-off Protection and Payment Plan, you must fall under at least one of the two following categories:

1. You receive one of the following:
- Assistance from a state emergency relief program
- Food stamps
- Medicaid
2. You are currently age 65 or older.*
Please Check All That Apply*

I receive assistance from a state emergency relief program.I receive food stamps/SNAP.I receive Medicaid.I am currently age 65 or older.
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Electric Service Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Holland BPW Electric Account Number*
Where can I find my account number?
Driver's License or Michigan ID Number*
Please upload a photo or scan of your driver's license or other form of ID listing birthdate to verify your age.*

Cancelof
Please upload a photo or scan of your food stamps or Bridge card.*

Cancelof
Please upload a photo or scan of your Medicaid insurance card.*

Cancelof
Please upload a photo or scan of proof of your state emergency relief assistance.*

Cancelof
Should be Empty:

Winter Shut-off Protection & Payment Plan Application