incomplete applications will not be processed€¦ · applying for gap may also qualify you for...

Dear Friend,

The Heat and Warmth Fund (THAW) and DTE Energy want to make it easier for you to get the help

you need on your energy bills. If you are a DTE Energy customer struggling to pay your gas and/or

electricity bill(s), you can apply for the 2017 Gateway Assistance Program (GAP), which provides a

one-time payment for past due account balances up to $6,000. You can visit our website

www.thawfund.org to complete an online application or download a printable application. You can

also complete an application in person at our office located at 535 Griswold St., Suite 200 Detroit, MI

48226.

Applying for GAP may also qualify you for additional assistance programs. THAW may refer eligible

customers to the following:

DTE LSP affordable payment plan, which allows customers to make affordable monthly

payments based on their income level. If you are approved for one-time GAP assistance,

THAW will send you a follow-up letter this fall when the LSP enrollment season begins. Just

sign and return the letter to THAW to sign up for the program. Check your mailbox this fall

for details.

Refrigerator Replacement program: Is your refrigerator more than 17 years old? If so,

you may qualify to receive a free refrigerator and recycling of your old appliance.

Remember to check the box about your refrigerator in the application.

Home Heating Credit from the State of Michigan to help you pay some of your heating

expenses if you are a qualified homeowner or renter.

HOW TO APPLY FOR GAP ASSISTANCE 1. Review the 2017 Program Guidelines to see if you meet the eligibility requirements.

2. Complete an application and include copies of all supporting documents listed in the

checklist.

3. Mail or drop off the completed application to THAW for review and processing:

The Heat and Warmth Fund, 535 Griswold St., Suite 200 Detroit, MI 48226

Once THAW receives your completed application, it will be reviewed by our Utility Assistance Center,

and an approval or denial letter will be mailed to your home. If you are approved, the amount of

assistance payment will be included in your letter. It may take up to 30 days for the assistance

payment to be reflected on your utility account.

We are here to help. If you have questions, please visit our website at www.thawfund.org or call

1-800-866-THAW (8429) to speak to a THAW Utility Assistance Specialist.

Thank you,

Saunteel Jenkins Saunteel Jenkins, MSW

Chief Executive Officer

INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED

An eligible household may apply for assistance as many times as needed up to a $6,000 cap.

Account must be residential (not a commercial account).

Account must be active, or recently active within the last 12 months.

Account must have a past due balance (usage arrearage).

Total owning (past due) cannot exceed $6,000.

Applicant must pay illegal or unauthorized usage charges and security fees before assistance

can be received.

Applicant must be the account holder. If the account is not in the applicant’s name, he/she must

accept responsibility for the bill with a valid ID, such as a passport, driver’s license, or state-

issued ID. If you're applying for someone else, you must provide

o all documents required to process the application; and

o a signed letter from the account holder granting the applicant permission to apply on

his/her behalf.

If services are not restored within 30 days of THAW commitment, funds will be removed from

account. Clients must have active service within 30 days.

HOUSEHOLD INCOME

Proof of income is required for all household members.

A household is income eligible with an income of not more than 200% of the federal poverty

level. The following 2016 Federal Poverty Guidelines for monthly income will be in effect.

Monthly Income Guidelines

Household Size 1 Person 2 Person 3 Person 4 Person 5 Person 6 Person 7 Person 8 Person

$1,980 $2,670 $3,360 $4,050 $4,740 $5,430 $6,120 $6,810

For each additional household member, add $690.00.

PLEASE NOTE

The following services do not qualify as usage arrearage

unauthorized or illegal usage

utility/energy provider unregulated services (e.g. appliance repair)

bankruptcy

Please use this checklist to make sure you include all appropriate information required to process your application. Completion of this application does not prevent shut-off or guarantee that your services will be restored. Applications that are missing required

documentation will be considered incomplete.

DOCUMENT CHECKLIST

Copy of valid photo ID for the applicant, such as a driver’s license or

•state-issued ID.The address on the ID must match the service address on the account. If not,you must provide another document validating the address for the account holder/applicant.

Copy of your most recent DTE Energy bill

Paycheck

Social

Statem

entSSI

Statemen

TANF S

tateme

If the account holder is not present, the applicant must provide a signed letter from the account holder granting permission to apply on their behalf.

Provide one (1) paystub from the prior 30 days OR a 2016 Income Tax Return.

Also include Child Support, Unemployment benefits, Social Security income, Veterans Affairs benefits, Cash Assistance, (FIP), Adoption Subsidy/Direct Care, Worker’s Compensation, Alimony, Interest Annuities or Dividends, Self-employment.

If you have no income, submit a Zero income affidavit (form included within this packet).

If you are self-employed and earn more than $8,500, you must provide supporting documentation.

THAW DTE GAP 2017

INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED OR RETURNED.

Completed and signed application

Copy of the applicant's social security card and the social securitynumbers of all other household members.

Proof of income for ALL members of the household for the prior 30 days

If you are self-employed and earn less than $8,500, submit a Self-declaration of Income (form is included within this packet).

Number of pregnant individuals in the household? # _____________

Do you own or rent your home? ☐ Own ☐ Rent

THAW DTE GAP 2017

Is the applicant a veteran? ☐ Yes ☐ No

Is your refrigerator more than 17 years old? ☐ Yes ☐ NoIf yes, would you like your refrigerator replaced for free? ☐ Yes ☐ No

E-mail Address: _______________________________________________________________________________________________________________________________________

THAW DTE GAP 20174

for each.

Income Expenses

Health Insurance Premium

Amount

Court ordered child support

Amount

Actual child care costs paid by an employed household member, not DHHS Amount

Unusual employment related expenses

Amount

$ Explain Expense

Signature Requirement

verify my eligibility for assistance.

I authorize my energy company to release by phone, fax, email or their computer website all available

Under penalties of perjury, I swear or affirm that this application has been examined by or read to me. If I am athird party applying on behalf of another person, I swear that this application has been examined by or read to theapplicant.. To the best of my knowledge, the facts are true and complete.

Signature of applicant or head of household Date Signature of spouse Date

Address (Numbers & Street Name, Apt., etc.) Date

Current phone number

Request for Review

in 10 u or your

of this form.

guarantee payment of funds, even if preliminary approval is granted. I hereby release THAW Fund, its employees, officers, directors and its partnering

THAW DTE GAP 20175

I authorize THAW and my utility company to retain information provided in this application (a) to contact me by phone, e-mail, fax, and/or mail regarding other assistance programs, and with my permission (b) to enroll me or another household account holder in another THAW assistance program(s).

E-mail Address

SUBMIT COMPLETED APPLICATION TO THAW, 535 GRISWOLD ST., SUITE 200, DETROIT, MI 48226

Applicant Name: ____________________________________________________________________________________

Signature ________________________________________________ Date __________________________

I am self-employed in the business of: ___________________________________________________________________

I have been self-employed in this manner since: ____/_____/_________

❒ previous year’s tax return ❒ accountant’s/bookkeeper’s statement ❒ business receipts/check stubs ❒ other _______________________________________________

If none of the above is available, please state the reason why: ________________________________________________

__________________________________________________________________________________________________

Signature ________________________________________________________ Date __________________________ THAW DTE GAP 2017

* Include a copy of Michigan Department of Health and Human Services (MDHHS) award letter verifyng active case status and services being received when completing this form.

Address: __________________________________________________________________________________________

__ I hereby certify that myself and any person in my household 18 or older does not receive income from any of the sources listed below:

__ I hereby certify that the following household members 18 or older do not receive income from any of the sources listed below:

___________________________________ _________________________________ ________________________________

a. Wages from employment (including tips, commissions,bonuses, fees, etc.)b. Income from operation of a businessc. Rental income from real or personal propertyd. Social Security payments, pensions, annuities, retirement funds, insurance policies of death benefits.e. Unemployment or Disability paymentsf. Public assistance paymentsg. Periodic allowances such as alimony, child support or gifts receivedh. Sales from self-employmenti. Any other source not named above

To the best of my knowledge, I estimate to earn $__________________ Weekly / Bi-Weekly / Monthly

*Please provide the names of the household members with zero income.

THAW DTE GAP 2017

Household Needs Assessment Questionnaire

THAW is requesting your completion of this questionnaire to help us learn more about what you or other household members may need. This survey can help connect you to resources or services in your area through our network of partner agencies and allow us to provide you with information on accessing those resources.

Please check all areas for preferred assistance/wraparound services:

☐ Clothing assistance ☐ Employment & Job Training☐ Food pantry ☐ Free tax preparation☐ Health & Wellness/Disease Prevention ☐ Rental & Mortgage Assistance☐ Transportation Assistance☐ Weatherization☐ Youth Programming

1.) What is your preferred form of communication regarding wraparound services/programming?

☐ Telephone

☐ Email @ .

2.) What other feedback would you like to provide on this needs assessment questionnaire?

_________________________________________________________________________________________________

Thank you for your participation!

☐ Daycare & early childhood education☐ Family Budgeting☐ Mental Health Counseling☐ Tutoring☐ Education☐ Emergency medical or financial assistance☐ First-time home buying & affordable housing☐ Meals on wheels☐ Other ________________________________

THAW DTE GAP 2017

Household Needs

Assessment Questionnaire

THAW is requesting your completion of this questionnaire. Your responses will help us learn more about what you or members of your household may need in order provide you access to services that provide financial stability in your household. THAW can connect you to resources or services in your area through our partner agencies.

□ Clothing assistance

□ Employment & Job Training

□ Food pantry assistance

□ Free Tax Preparation

□ Daycare & Early childhood education

□ Family Budgeting

□ Mental Health Counseling

□ Tutoring

□ Disease Prevention

□ Rental & Mortgage assistance

□ Transportation assistance

□ Weatherization

□ Youth programming

□ Education

□ Emergency medical or financial assistance

□ First Time Home Buying & Affordable housing

□ Meals on wheels

□ Other__________________________

1.) How often would you like to meet with a case manager to discuss wraparound services offered to you?

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

About You (optional)

Gender Male _____ Female ______

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

Household Needs

□ Tutoring

□ Weatherization

□ Education

□ Meals on wheels

□ Other__________________________

(check one)

Weekly

Monthly

Quarterly

(check one)

Telephone

Age group _____18-25 ____26-35 ___36-55 ____56-65 ____over 65

County of residence

incomplete applications will not be processed€¦ · applying for gap may also qualify you for...

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