Energy Documentation Form

THIS FORM IS ONLY FOR PARTICIPANTS THAT CURRENTLY HAVE A SCHEDULED APPOINTMENT FOR ENERGY ASSISTANCE

Thank you for applying for Energy Assistance through Self Enhancement. In order for us to determine eligibility, we must collect documentation from you. A list of those required documents can be found on our website at www.selfenhancement.org/energy. If you have questions or concerns, please email us at energy@selfenhancement.org or call us at 503-240-0828.

Applicant Name*

Do you currently have a scheduled appointment?*

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STOP. APPOINTMENT NEEDED FIRST.

PLEASE CALL: 503-713-5590 TO MAKE AN ENERGY ASSISTANCE APPOINTMENT FIRST.

Documents uploaded without a scheduled appointment will be deleted.

What is your appointment confirmation number?*

Applicant Phone Number*

Applicant Email

Monthly Rent or Mortgage amount you pay*

Today's Date

File attachments to upload*

You will need to upload the following documents for all members living in your household: Picture IDs for all people 18+, Social Security Cards, current utility bill, and gross income verification. For more details please visit www.selfenhancement.org/energy. Please note that all photos must be clear and legible.

Drag and drop files here or

By clicking ‘submit’ you are providing the above documentation to SEI’s Energy Program.*

Self Enhancement, Inc. (SEI) respects the privacy of our users. If choosing to apply for assistance, identifiable documentation is required in order to determine eligibility. Documentation provided through this site is stored on a secure server through Smartsheet. Information provided is solely for the use of SEI’s Energy Assistance Program and will not be shared. Applying for our Energy Assistance Program is voluntary. You are under no obligation to provide us with personal information; however, your refusal will limit and in some cases inhibit our ability to provide you with an energy appointment.

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