Energy Discount Enrollment

Apply for a discounted energy rate. Required fields are marked with an asterisk (*).

Account Holder

Full Name

Email Address

ZIP Code

* Qualification Method (Choose One) (required)

Annual Household Income

Public Assistance Program (e.g., SNAP, SSI, Medicaid)

Annual Household Income (whole dollars)

I am currently on a fixed income

Select every program your household participates in:

SNAP (Food Assistance)

Supplemental Security Income (SSI)

Medicaid

Energy Assistance (LIHEAP)

Assisted Enrollment

Is an outreach worker helping you fill out this form?

YES

Outreach Worker ID