Virgin Islands Energy Office WAP Eligibility Survey

Virgin Islands Energy Office

WAP Eligibility Survey

This survey is designed to gather preliminary information from potential applicants to the WAP program so that the VIEO team can reach out when the program launches. Please be sure to review the income thresholds at Energy.vi.gov to ensure that you are eligible.

First Name*

Last Name*

Home Phone*

Phone

Other Phone

Phone

Email Address

District

St. Croix

St. Thomas

St. John

Physical Address*

City*

State*

Zip Code*

Are you 60 or older?*

Yes

No

Do you have a disability?*

Yes

No

Are you the only person in your household? (Do you live alone?)*

Yes

No

Are you the head of your household?

Yes

No

Does your household contain...

Select all that apply

Children under 5

Children between 6 and 18

No Children

Is anyone else in your household over 60?

Select or enter value

Does anyone else in your household have a disability?

Select or enter value

Do you currently qualify for or receive assistance from any of the following low-income programs?*

Select all that apply

SNAP

TANF

Energy Assistance

Medicaid

Other

I do not qualify for any assistance programs

Please list other programs in which you participate.

Send me a copy of my responses

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