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FACT SHEET
SOLAR FOR ALL
Now you can benefit from solar. Community solar is making clean solar energy available to more New Yorkers than ever before. Through Solar for All, eligible residents can subscribe to community solar with no upfront costs, no monthly payments, and no fees whatsoever.
How it WorksSolar for All allows you to go solar—no equipment required. Solar panels are installed at a site in your community rather than on individual roofs. The generated electricity is then fed into the local power grid, increasing the amount of available clean energy while decreasing electricity generated by fossil fuels. Area residents can subscribe to the community solar project and receive credits on their regular utility bill for the clean energy produced. Depending on the community solar project size, dozens or even hundreds of community members can subscribe to a single project.
JOIN at no costSAVE moneyUSE clean energy
call: 1-877-NYSMART
email: [email protected]
visit: nyserda.ny.gov/solar-for-all
1
Solar panels areinstalled at a site in
your community.
2
The clean energyis then fed into thelocal power grid.
3
You continue to getelectricity from your utility,
with no need to installor maintain panels on
your home or property.
$
4
Subscribe to acommunity solar project
& receive credits onyour existing bill.
Why participate?• Save money. Save on your monthly electricity bills with credits from your community solar subscription,
which will appear automatically.
• No hassle. No long-term commitment, costs, fees, or payments are required to participate, and you can cancel at any time. You will not need to install or maintain solar equipment on your property or change anything with your utility.
• Good for the environment. Your participation promotes a cleaner environment for your family and community by reducing air pollution and greenhouse gas emissions.
Who is eligible?You may be eligible for Solar for All if you meet all of the following requirements:
• Live in New York State, regardless if you own or rent.
• Pay your own electric bill.
• Have a household income below 60% of the State median income. Visit nyserda.ny.gov/solar-for-all-eligibility to see if you qualify.
• Receive electricity from Central Hudson Gas & Electric, Con Edison, National Grid, NYSEG, Orange and Rockland, or Rochester Gas & Electric.
• Households with low electricity use (under 2,000 kilowatt hours in the last 12 months) are not eligible.
How to sign up• Submit an application. A copy of your latest electric bill and documentation of income eligibility is required.
• You will find out if you are eligible within a few days of submitting the application.
• After confirming eligibility, you will be matched to a community solar project in your area.
• If space isn’t available in your area, you’ll be put on a waitlist. You will be contacted when more spots become available.
• Once you’re connected with a project, you’ll earn credits on your current electricity bill and lower your energy costs.
Get startedVisit nyserda.ny.gov/solar-for-all to fill out an online application, request a paper application, or get answers to frequently asked questions.
To ask a question or request additional information about Solar for All, email [email protected] or call 1-877-NYSMART.
LMI-SFA-cons-fs-1-v1 6/18
NY-Sun, a dynamic public-private partnership, will drive growth in the solar industry and make solar technology more affordable for all New Yorkers. NY-Sun brings together and expands existing programs administered by the New York State Energy Research and Development Authority (NYSERDA), Long Island Power Authority (LIPA), PSEG Long Island, and the New York Power Authority (NYPA), to ensure a coordinated, well-supported solar energy expansion plan and a transition to a sustainable, self-sufficient solar industry.
NYSERDA, a public benefit corporation, offers objective information and analysis, innovative programs, technical expertise, and support to help New Yorkers increase energy efficiency, save money, use renewable energy, and reduce reliance on fossil fuels. NYSERDA professionals work to protect the environment and create clean energy jobs. NYSERDA has been developing partnerships to advance innovative energy solutions in New York State since 1975. To learn more about NYSERDA’s programs, visit nyserda.ny.gov or follow us on Twitter, Facebook, YouTube, or Instagram.
FACT SHEET
COMMUNITY ENERGY ENGAGEMENT PROGRAM
Learn about resources and funding available in your community for energy projects
There is support available to help residents and businesses reduce their energy consumption and energy costs and make informed energy decisions. Community Energy Advisors can connect you to resources and networks that provide cost-saving opportunities in your communities.
Benefits of working with a Community Energy Advisor
Community Energy Advisors are available to:
• Enable you to make informed energy decisions.
• Inform you of financing options for energy efficiency and renewable energy projects and products.
• Guide you through the process of implementing a clean energy project.
• Connect you with the right energy contractors who can implement clean energy projects.
LEARN about clean energy programs and resourcesACCESS network of community and local partnershipsGET HELP identifying and engaging the right contractorRECEIVE assistance with loan applications
contact: your local Community Energy Advisor listed on the reverse side of this fact sheet
visit: nyserda.ny.gov/ceep
CAPITALREGION
LONGISLAND
NEWYORKCITY
WESTERNNEW YORK
FINGERLAKES
CENTRALNEW YORK
MID-HUDSON
S
MOHAWKVALLEY
OUTHERN TIER
NORTHCOUNTRY
YATES
NIAGARA
ERIE
CHAUTAUQUA
CATTARAUGUS
ALLEGANY
ORLEANS
GENESEE
WYOMING
MONROE WAYNE
LIVINGSTON
ONTARIO
YATES
SENECACAYUGA
STEUBEN
CHEMUNG TIOGA BROOME
SCHUYLERTOMPKINS
ONONDAGA
CORTLANDCHENANGO
MADISON
OSWEGO
ONEIDA
LEWIS
JEFFERSON
ST. LAWRENCE
FRANKLINCLINTON
ESSEX
HAMILTON
HERKIMER
FULTON
WARREN
OTSEGO
DELAWARE
SULLIVAN
ULSTER
ALBANY
GREENE
SCHOHARIE
SARATOGA
WASHINGTON
SCHENECTADY
COLUMBIA
RENSSELAER
DUTCHESS
MONTGOMERY
PUTNAMORANGE
ROCKLAND
WESTCHESTER
BRONX
NASSAU
SUFFOLK
QUEENSKINGS
NEWYORK
RICHMOND
Community Energy Advisors By Region
WESTERN NEW YORKNatalie Rodriguez People United for Sustainable Housing, Inc (PUSH)[email protected](716) 886-1780
NYSERDA, a public benefit corporation, offers objective information and analysis, innovative programs, technical expertise, and support to help New Yorkers increase energy efficiency, save money, use renewable energy, and reduce reliance on fossil fuels. NYSERDA professionals work to protect the environment and create clean energy jobs. NYSERDA has been developing partnerships to advance innovative energy solutions in New York State since 1975. To learn more about NYSERDA’s programs, visit nyserda.ny.gov or follow us on Twitter, Facebook, YouTube, or Instagram.
CLG-CEEP-ov-fs-1-v9 7/19
CAPITAL REGIONKathleen LangtonAffordable Housing Partnership of the Capital Region [email protected](518) 434-1730 x414
CENTRAL NEW YORKBrendon FoxHome [email protected](315) 459-6645FINGER LAKES
Courtney [email protected](585) 546-3700 x3025
LONG ISLANDBarbara BurkeUnited Way of Long [email protected](631) 940-3731
MID-HUDSONCollin AdkinsCornell Cooperative Extension Dutchess [email protected] (845) 677-8223 x113
MOHAWK VALLEYCabryn GurdoMohawk Valley Economic Development District, Inc. [email protected] (315) 866-4671
NEW YORK CITYNYC CEEP HotlineThe Center for New York City [email protected](646) 760-4030
NORTH COUNTRY Guillermo MetzCornell Cooperative Extension Tompkins [email protected](607) 272-2292
SOUTHERN TIERKarim Beers Cornell Cooperative Extension Tompkins County (CCETC) [email protected](607) 272-2292
Get Started Visit nyserda.ny.gov/ceep or contact a Community Energy Advisor listed below.
* Community Energy Advisors are not responsible for submitting program documentation or grant or loan applications.
Most New York homeowners can receive a home energy assessment for free or at a reduced-cost through the Home Performance/ Assisted Home Performance with ENERGY STAR® program. The assessments are available on a first come, first served basis. Save time and apply online at nyserda.ny.gov/apply-online
To qualify, you need to meet these requirements:1. You must be the owner, or be authorized to sign for the owner, of a 1- to 4-unit residential building.*2. Your total household income must meet the guidelines on page 2.3. You must not have previously received a free or reduced-cost assessment on the building listed below.
SECTION D: ELIGIBILITY DECLARATIONMy signature certifies that I am financially responsible for the account(s) listed on this application. I hereby consent and authorize the electricity and fuel suppliers named in this application to release any and all energy usage information, including account number(s), related to the above property address, to representatives of the New York State Energy Research and Development Authority (NYSERDA), and the Weatherization Assistance Program (WAP), and/or its designated representatives for the period beginning two years prior to the application date and ending three years after program participation. I understand that this information will be kept confidential, to the extent permitted by law, and used only for the purpose of determining program eligibility, estimating energy savings, program implementation, and evaluation, including the evaluation of achieved energy savings.
X
Applicant/Homeowner’s Signature Date
When complete, please mail or email the signed application to: Mail: Home Energy Assessments Email: [email protected] 2 Wall Street Albany, NY 12205
❏ Please send a copy of my home energy assessment Reservation Number to the Home Performance Contractor that I have chosen below. NYSERDA does not assign contractors.
Contractor Name
SECTION A: APPLICANT INFORMATION
First Name Middle Initial Last Name
NYBuilding Address City County State Zip
Mailing Address (if different than the above) City State Zip
( ) ( )Primary Phone Secondary Phone Email Address
Residential Building Type (5+ units do not qualify)*
❏ Single Family ❏ 2-Unit ❏ 3-Unit ❏ 4-Unit
SECTION B: HOUSEHOLD INCOME RANGEIs your household income less than $43,120? ❏ Yes ❏ No
If no, then please refer to attached chart and indicate your annual household income range below. ❏ ≤ 80% AMI** ❏ ≤ 200% AMI ❏ ≤ 250% AMI ❏ ≤ 300% AMI ❏ ≤ 350% AMI ❏ ≤ 400% AMI
SECTION C: HOW DID YOU HEAR ABOUT HOME PERFORMANCE WITH ENERGY STAR? (Optional)
Please select all that apply:❏ Print Ad ❏ TV ❏ Radio ❏ Internet ❏ Event/Home Show ❏ Neighbor/Friend/Family ❏ Contractor ❏ Clean Energy Community Coordinator ❏ Real Estate Professional ❏ Town, Village, City, County ❏ NYSERDA ❏ Constituency-based Organization Name:
* Condo, co-op, not-for-profit, or mobile home owners please call 1-877-NYSMART to see if you are eligible.
** Area Median Income (AMI) represents the statistical midpoint in household earnings for each county.
Need Help? Call 1-877-NYSMART
Page 1 of 2 HP-web
Residential ASSESSMENT APPLICATION
❏ Mobile Home
Is your home greater than 3,500 sqare feet? ❏ Yes ❏ No
Electric Utility Name:(PSEG Long Island electric customers may apply for an energy assessment directly through their utility)
Gas Utility Name:
County Name ≤ 80% ≤ 200% ≤ 250% ≤ 300% ≤ 350% ≤ 400%
Albany $66,480 $166,200 $207,750 $249,300 $290,850 $332,400Allegany $43,120 $107,800 $134,750 $161,700 $188,650 $215,600Broome $52,560 $131,400 $164,250 $197,100 $229,950 $262,800Cattaraugus $47,440 $118,600 $148,250 $177,900 $207,550 $237,200Cayuga $52,480 $131,200 $164,000 $196,800 $229,600 $262,400Chautauqua $44,800 $112,000 $140,000 $168,000 $196,000 $224,000Chemung $51,680 $129,200 $161,500 $193,800 $226,100 $258,400Chenango $45,280 $113,200 $141,500 $169,800 $198,100 $226,400Clinton $55,440 $138,600 $173,250 $207,900 $242,550 $277,200Columbia $59,680 $149,200 $186,500 $223,800 $261,100 $298,400Cortland $51,920 $129,800 $162,250 $194,700 $227,150 $259,600Delaware $47,200 $118,000 $147,500 $177,000 $206,500 $236,000Dutchess $71,520 $178,800 $223,500 $268,200 $312,900 $357,600Erie $54,560 $136,400 $170,500 $204,600 $238,700 $272,800Essex $52,960 $132,400 $165,500 $198,600 $231,700 $264,800Franklin $46,080 $115,200 $144,000 $172,800 $201,600 $230,400Fulton $45,840 $114,600 $143,250 $171,900 $200,550 $229,200Genesee $53,280 $133,200 $166,500 $199,800 $233,100 $266,400Greene $51,040 $127,600 $159,500 $191,400 $223,300 $255,200Hamilton $51,040 $127,600 $159,500 $191,400 $223,300 $255,200Herkimer $49,680 $124,200 $155,250 $186,300 $217,350 $248,400Jefferson $49,920 $124,800 $156,000 $187,200 $218,400 $249,600Lewis $46,240 $115,600 $144,500 $173,400 $202,300 $231,200Livingston $54,880 $137,200 $171,500 $205,800 $240,100 $274,400Long Island: Nassau & Suffolk $88,640 $221,600 $277,000 $332,400 $387,800 $443,200Madison $54,400 $136,000 $170,000 $204,000 $238,000 $272,000Monroe $54,880 $137,200 $171,500 $205,800 $240,100 $274,400Montgomery $46,480 $116,200 $145,250 $174,300 $203,350 $232,400New York City: Bronx, Kings, New York, Queens, Richmond $52,960 $132,400 $165,500 $198,600 $231,700 $264,800Niagara $54,560 $136,400 $170,500 $204,600 $238,700 $272,800Oneida $49,680 $124,200 $155,250 $186,300 $217,350 $248,400Onondaga $54,400 $136,000 $170,000 $204,000 $238,000 $272,000Ontario $54,880 $137,200 $171,500 $205,800 $240,100 $274,400Orange $71,520 $178,800 $223,500 $268,200 $312,900 $357,600Orleans $54,880 $137,200 $171,500 $205,800 $240,100 $274,400Oswego $54,400 $136,000 $170,000 $204,000 $238,000 $272,000Otsego $49,760 $124,400 $155,500 $186,600 $217,700 $248,800Putnam $52,960 $132,400 $165,500 $198,600 $231,700 $264,800Rensselaer $66,480 $166,200 $207,750 $249,300 $290,850 $332,400Rockland $82,880 $207,200 $259,000 $310,800 $362,600 $414,400Saratoga $66,480 $166,200 $207,750 $249,300 $290,850 $332,400Schenectady $66,480 $166,200 $207,750 $249,300 $290,850 $332,400Schoharie $66,480 $166,200 $207,750 $249,300 $290,850 $332,400Schuyler $49,520 $123,800 $154,750 $185,700 $216,650 $247,600Seneca $51,600 $129,000 $161,250 $193,500 $225,750 $258,000St. Lawrence $46,160 $115,400 $144,250 $173,100 $201,950 $230,800Steuben $47,520 $118,800 $148,500 $178,200 $207,900 $237,600Sullivan $51,440 $128,600 $160,750 $192,900 $225,050 $257,200Tioga $52,560 $131,400 $164,250 $197,100 $229,950 $262,800Tompkins $60,480 $151,200 $189,000 $226,800 $264,600 $302,400Ulster $62,800 $157,000 $196,250 $235,500 $274,750 $314,000Warren $51,280 $128,200 $160,250 $192,300 $224,350 $256,400Washington $51,280 $128,200 $160,250 $192,300 $224,350 $256,400Wayne $54,880 $137,200 $171,500 $205,800 $240,100 $274,400Westchester $89,120 $222,800 $278,500 $334,200 $389,900 $445,600Wyoming $53,360 $133,400 $166,750 $200,100 $233,450 $266,800Yates $50,880 $127,200 $159,000 $190,800 $222,600 $254,400
HOUSEHOLD INCOME GUIDELINES 2018
HOME ENERGY ASSESSMENT FEE SCHEDULE Household
Income Range
Single-Family HomesLess than 3,500 Square Feet*
2-4 Unit Residential Building orSingle Family Homes ≥ 3,500 Square Feet*
Cost to Customer
NYSERDA Payment to Contractor
Cost to Customer
NYSERDA Payment to Contractor
≤ 80% AMI - 0 - $250 - 0 - $400
≤ 200% AMI - 0 - $250 - 0 - $400
201-250% AMI $50 $200 $80 $320
251-300% AMI $100 $150 $160 $240
301-350% AMI $150 $100 $240 $160
351-400% AMI $200 $50 $320 $80
> 400% AMI Market Rate - 0 - Market Rate - 0 -
*Above grade conditioned space.
Page 2 of 2SFR-HP-AHP-assessment-app-1-v6 5/18
DETERMINE YOUR HOUSEHOLD INCOME RANGEIf your household income is greater than $43,120, use the chart below to find where it falls in relation to your county’s median income. This will determine the cost, to you, of your home energy assessment (if any).1. Find your county (this is where the home you wish
to have assessed is located).2. Use the corresponding columns to find the range
that includes your household income. 3. Check the appropriate box on the front of the application.4. Use your household income range from the chart below and the chart to the right to determine the cost, to you, of your assessment (if any).
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 serve basis.
General Applicant Information (Sections A, B & C) – Verify that all required fields are completed (unless marked as “optional”).
Energy Information (Section D):
Sign Customer Fuel/Energy Bill Release Authorization
Include a copy of complete Electric Bill
Include a copy of complete Gas Utility Bill or bill from Fuel Supplier if heating by propane, oil, kerosene, wood or coal
Income Information (Section E)
Complete table listing all household members and their income.
Income (Section F) (gross income calculations and required documentation documents are listed on page 4).
Award letter for ONE of the following: HEAP, SNAP (Food Stamps), TANF (Temporary Assistance for Needy Families) or Supplemental Security Income dated within the past 12 months
or
All household gross income for the last month:
Pay stubs
Social Security and Social Security Disability
All forms of income including disability, worker’s compensation, unemployment, pension, maintenance, annuities, Veteran’s benefits and all other income
Self Employment
OWNERS ONLY:
Include ONE of the following as Proof of Ownership:
Current Property/School Tax Bill
Deed
Bill of Sale for mobile/manufactured homes
Mortgage Statement
RENTERS ONLY:
Landlord Name, Address and Phone Number provided in Section B
Applicant Affirmation (Section G)
Read and sign
Attachment 1 – Frequently Asked Questions and Personal Privacy Protection Law Provisions
Keep for your records
Weatherization Assistance ProgramEmPower New York Program
APPLICATION CHECKLIST
Page 1
Page 2
SECTION A: APPLICANT INFORMATION
Name Social Security Number
Address Apt #
City State Zip
County Primary Phone (include area code) Secondary Phone (include area code)
SECTION B: DWELLING INFORMATION
The following information will help determine which programs are the most appropriate for you. Please print clearly and provide as much information as possible.
Mailing Address (if different from above)
Additional Contact Person Relationship to Applicant Phone Number (include area code)
Weatherization Assistance ProgramEmPower New York Program
APPLICATION
q I own q I rent I have lived here ______ years Approximate age of the home_______________
q Single-Family q Multifamily ___ # of units q Manufactured/mobile home q Group home/shelter
If you rent, certain upgrades require owner permission. Please provide owner information below:
Owner’s Name:
Address:
Phone (include area code):
Who pays for the heat at the dwelling? q I pay q Owner
Who pays for the electric at the dwelling? q I pay q Owner
Does your roof leak? q Yes q No If yes, which rooms: ____________________________________
Do you own your refrigerator? q Yes If yes, about how old is it? _______ years q No
Do you use a second refrigerator? q Yes If yes, about how old is it? _______ years q No
Do you use a separate freezer? q Yes If yes, about how old is it? _______ years q No
SECTION C: HOUSEHOLD DEMOGRAPHICS
Total number of members in the household: ________
Please indicate the number of household members who are:
60 years of age or older _____ Persons with disabilities _____
Native American _____ Children age 17 years or younger _____
NY
Page 3
SECTION D: ENERGY INFORMATION
Property Address: _________________________________________________________________________________
My primary heating fuel is:
q Electric q Oil q Kerosene q Natural Gas q Propane q Wood
q Pellets q I don’t know q Other: __________________________
My secondary heating fuel is:
q Electric q Oil q Kerosene q Propane q Wood q Pellets q Coal
q I do not have secondary fuel q Other: ______________________
Secondary Supplier Name: ____________________________ Account Number: ______________________________
My water heater runs on:
q Electric q Oil q Natural Gas q Propane q I don’t know
ELECTRIC UTILITY: If you are responsible for the electric bill, provide the following:
Utility Name: Name on Account:
Account Number: 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: Name on Account:
Account Number: 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: Account Number:
Do you have a maintenance agreement for your heating system? q Yes q No
If yes, list the name of the maintenance provider:
CUSTOMER AUTHORIZATION for Release of Fuel/Energy Bills (for previous two years and future three years)
My signature below certifies that I am financially responsible for the account(s) listed above. I hereby consent and authorize my electricity and fuel suppliers to release any and all energy consumption information, including account number(s), related to the above property address, to representatives of the Weatherization Assistance Program (WAP), and to the New York State Energy Research and Development Authority (NYSERDA) and/or its designated representatives for the period beginning two years prior to the application date and ending three years after participation in the programs which provide services to my dwelling. I understand that this information will be kept confidential, to the extent permitted by law, and used only for the purpose of determining program eligibility and savings.
Customer Signature: __________________________________________ Date: __________________
SECTION C: HOUSEHOLD DEMOGRAPHICS (CONTINUED)OPTIONALPlease add any information that we may find helpful in reducing your energy consumption and list occupant health issues or special needs that we need to be aware of:
SECTION F: INCOME DOCUMENTATION
Page 4
SECTION E: INCOME INFORMATION
A. q 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
B. q Only if you cannot provide one of the documents listed under A, provide income documentation as follows:
• All household gross income for the last month: Pay stubs. To obtain monthly income total, if income is:
- 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 Social Security Disability: copy of award letter
• Documentation of all forms of income including 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
Include the following information for each household member. Name Gender Age Student
(Yes or No)Source(s) of income
Weekly Monthly Yearly
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Total Income for the Household $ $ $
q Check here if you have received HEAP within the past 12 months.
I authorize release of my contact information, dwelling information, and income documentation to representatives of the Weatherization Assistance Program (WAP), to NYSERDA and/or its designated representatives, to any community-based organizations identified on this application, and to my utilities. I understand that the information provided by me will be used only for the purposes of determining eligibility for the WAP, eligibility for NYSERDA programs and financial incentives, and for estimating and evaluating energy savings. I understand that all information will be kept confidential, to the extent permitted by law. I understand that if energy efficiency services are provided to me through WAP or NYSERDA’s EmPower New York program, there will be no cost to me and that 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 also understand that I will not be eligible to receive financial incentives or rebates from an electric or natural gas utility for measures provided at no cost through the WAP or NYSERDA programs.
I agree to provide the WAP representatives, NYSERDA 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, and Quality Assurance 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 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 WAP, and their designees, to assure my eligibility for the WAP and NYSERDA’s programs. 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). I have read and understand the provisions of the Personal Privacy Protections Law in Attachment #1.
XApplicant Signature Date
XApplicant Representative Signature Date
SECTION G: APPLICANT AFFIRMATION
Page 5
AGENCY USE ONLY
Reviewed By: q HEAP q OFA q Utility q Weatherization Subgrantee q EmPower q Other: _________________
Check all benefits that the household receives: q SSI q HEAP q SNAP q TANF
On the basis of the information provided by the applicant, the household is determined to be:
q Eligible for Weatherization q NOT Eligible for Weatherization
q Eligible for EmPower q NOT Eligible for EmPower q EmPower eligible, but wait-listed for Weatherization
Check here if: q Household was previously served by Weatherization q Household ineligible for further services through EmPower
Additional Comments:
Agency Representative Signature: Date:
Title:
Agency:
LMI-EMP-wap-form-1-v6 5/17
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Page 6
Frequently Asked Questions EmPower New York and Weatherization Assistance Program
ATTACHMENT 1 - Keep for Your Records
Are services really free?Yes – State residents meeting the Weatherization or EmPower New York eligibility requirements can receive home energy services through the programs at no cost.
Do Weatherization and EmPower New York provide services to renters as well as owners?Yes – both programs provide energy services to anyone who owns or rents a home and meets all of the eligibility requirements. Owners of rental properties that receive Weatherization funds are generally required to contribute a portion of the cost of the work.
What are some of the no-cost energy services that Weatherization or EmPower New York may provide?• Replacement of old-style light bulbs with high-efficiency lighting.• Replacement of inefficient refrigerators and freezers with new ENERGY STAR® certified models.• Added insulation to keep your home more comfortable.• Strategic air sealing to reduce drafts.• Heating system upgrades and repairs.• Everyday strategies and tips to help you manage your energy costs.• Minor repairs to ensure that the installed energy efficiency materials will perform correctly.• Health and safety measures to help ensure indoor air quality. • Identification of any hazardous conditions discovered during the energy audit.
If I accept work from Weatherization and/or EmPower New York, is a lien going to be on my home? Am I required to pay the program back if I move or my income changes?There is no cost or future obligation for eligible residents that participate in the Weatherization Program or EmPower New York.
Do the contractors perform code inspections?No – Weatherization and EmPower New York contractors are not Code Enforcement Officials.
Can I hire my own contractor?No – all work will be completed by a contractor accredited by the Building Performance Institute (BPI), a national organization that sets the technical standards for contractors in energy efficient building performance, so you know they’re applying the latest knowledge and technology to the energy efficiency of your home.
Can I get paid back for work I have already performed?No – Weatherization and EmPower New York cannot reimburse you for work that has already been completed.
LMI-EMP-wap-form-1-v6 5/17
Page 7
Privacy Protection Information Weatherization Assistance Program
The New York State Personal Privacy Protection Law (Public Officers Law, Article 6-A) requires in §94(1)(d) that each subgrantee of the Weatherization Assistance Program that maintains a system of records provide each subject from whom it requests information with certain notifications as provided below.
Name of agency requesting and responsible for information:New York State Homes and Community Renewalwww.nyshcr.org
Authority for collection and principal purpose for which the information is collected:The Energy Conservation and Production Act (P.L. 94-385) §416 and §417 and the Low-Income Home Energy Assistance Act of 1981 (P.L. 97-35, as amended) require the State to keep records for the purposes of monitoring and evaluation and for the preparation of reports, and that eligibility for the program be established, which requires the collection of personal information, including the Social Security number of the applicant.
Effects of not providing the requested information:If information requested on the Weatherization Application is not provided, the applicant’s application may be delayed.
Routine uses for the collected information: This information is used by New York State Homes and Community Renewal and its subgrantees for administration of the Weatherization Assistance Program. Some of the information collected is aggregated and reported to the New York State Office of Temporary and Disability Assistance and to the United States Department of Energy. This information may also be used to perform data matches with other state and federal agencies, to verify your eligibility for assistance, and for improving delivery of services and program evaluation. No personally-identifiable information is used for this purpose.
Subgrantee Information:
When completing the application, make sure the contact person listed on the application is the same person listed on your electric utility bill. Before starting, have a copy of your most recent electric utility bill and required documents. You will need to submit these documents with your application. If you have any questions, contact us at [email protected] or 1-877-NYSMART.
SECTION 1. APPLICANT INFORMATION
First Name Last Name
NYAddress City State Zip
Provide your preferred means of communication with NYSERDA (select one)
❏ Phone Number
SECTION 2. HOUSEHOLD INFORMATION What is your utility company? (select one)
❏ Central Hudson Gas & Electric ❏ Consolidated Edison ❏ National Fuel ❏ National Grid
❏ New York State Electric & Gas (NYSEG) ❏ Orange and Rockland ❏ Rochester Gas & Electric (RG&E)
What is your utility account number?For NYSEG customers use your POD number. Typically, these numbers are located on the top of your electric bill.
Do you rent or own? ❏ I own ❏ I rent
Have you received assistance from HEAP and/or another federal or utility program within the last 12 months?
❏ Yes ❏ No ❏ Don’t Know
What is the primary way you heat your home?
❏ Gas ❏ Oil ❏ Electric ❏ Propane ❏ Wood ❏ Don’t Know
SECTION 3. HOUSEHOLD APPLICATION DOCUMENTSYou will need to include the following information with your application submission:
✓ Electric Utility DocumentationInclude your most recent electric utility bill.
✓ Income DocumentationYou can demonstrate income eligibility through two options.
Option 1Submit a copy of the award letter dated within the last 12 months for one of the following:
• HEAP (Home Energy Assistance Program)
• SNAP (Food Stamps)
• TANF (Temporary Assistance for Needy Families)
• Supplemental Security Income
APPLICATIONSolar for All Program
Option 2If you are unable to provide one of the documents listed in option 1, you must provide income documentation as follows:
• Completed Household Eligibility Worksheet (available at nyserda.ny.gov/solarforalleligibilty)
• Copy of award letter from Social Security and Social Security Disability
• Self-Employment IRS Report of Quarterly earnings for the past three months
• Documentation showing all forms of income, including disability, worker’s compensation, unemployment, pension, maintenance, child support, annuities, veteran’s benefits, and all other income
SECTION 4. APPLICATION SUBMISSIONSubmit your completed application along with electric utility and income documentation to:Solar for All2 Wall StreetAlbany, NY 12205
SECTION 5. APPLICANT AFFIRMATION
I understand that if a community solar subscription is provided to me through the Solar for All program, there will be no additional costs to me and participation in these programs will not affect my social security, public assistance, or any other income. I understand this application does not guarantee acceptance into the program or that the program will have community solar subscription available in my area. Whether or not a community solar subscription is provided will depend on the number of applications received, the availability of community solar subscriptions in your area, funds, and priorities established by the program.
I authorize release of my contact information and utility account information to NYSERDA, its designated representatives, the community solar project sponsor designated by NYSERDA, and my electric utility. I authorize release of my income and eligibility documentation to NYSERDA and its designated representatives, and I consent to any inquiry to verify or confirm the information I have given. I understand the information provided by me will be used only for the purposes of determining eligibility for NYSERDA’s residential programs and providing a Solar for All community solar subscription. I understand all information will be kept confidential to the extent permitted by law.
Applicant Signature Date
LMI-SFA-app-form-1-v1 6/18
