Medical Electric Affordability Application

How many people live in your household?*
How many people in your household have income?*
Income Sources (Check all that apply)*

Gross WagesSocial Security Benefits (SSA, SSDI,SDI)Supplemental Security BenefitsMN Family Investment Program (MFIP)General Assistance (GA)Diversionary Work (DWP)Veterans' BenefitsWorkers' CompensationUnemployment CompensationRetirement IncomePensionLong/Short term DisabilityAlimony/Spousal SupportSelf EmploymentNo Income right nowOngoing financial support from family and/or friendsChild Support (Not counted as income)Other
Enter total MONTHLY Gross Wages for all household members. (We do not include wages for K-12 students)*
Enter total MONTHLY Net income from Social Security benefits for all household members: (SSA/SSDI/RSDI,SSDI)*
Enter total MONTHLY Net income from Supplemental Security benefits (SSI) for all household members: *
Enter total MONTHLY income from MFIP (Minnesota Family Investment Program) for all household members: *
Enter total MONTHLY income from General Assistance for all household members: *
Enter total MONTHLY income from Diversionary Work Program for all household members: *
Enter total MONTHLY income from Veterans' Benefits for all household members: *
Enter total MONTHLY Gross income from Workers' Compensation for all household members: *
Enter total MONTHLY Gross income from Unemployment Compensation for all household members: *
Enter total MONTHLY Gross income from Retirement Income (Not Social Security) for all household members: *
Enter total MONTHLY Gross income from Pension for all household members: *
Enter total MONTHLY Gross income from Long Term or Short Term Disability for all household members: *
Enter total MONTHLY Gross income from Alimony or Spousal Support for all household members: *
Enter total MONTHLY Gross income from Ongoing support from family or friends for all household members: *
Self Employment: Add lines 3 + 4 + 5 and 6 on your 2023 IRS 1040 Schedule 1 tax form. If you did not file as self employed on your last return or if you did not file a return, enter your estimated net income from self employment for the year (Annually)*
If you have No Income, write a brief description of how you pay your monthly bills (mortgage/rent, food, utilities..)*
Please enter what your "other income" is in the space provided above, and enter total MONTHLY Gross income from that income source.*

Because you did not receive a grant from the Energy Assistance Program, you must provide proof of your income. Please select how you would like to send us your proof.*

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Mail your income verification to:

Energy CENTS Coalition

823 East 7th St

St Paul, MN 55106
email your income verification to:

ecc@energycents.org

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 to allow Xcel Energy to use payment information in the evaluation of the program.
- I agree to allow the Energy CENTS Coalition to obtain account information, including LIHEAP status, from Xcel Energy necessary to process this application.
- 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 understand that enrollment on this program is based on a first come first served basis.
- I agree to notify Xcel Energy and 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.
- I understand that I must have a certified medical form on file with Xcel Energy in order to be eligible for this program.
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Medical Electric Affordability Program Application