Energy Assist

Account No.*

Member Name*

Phone No.

Email Address*

Mailing Address

Street Address*

City*

State*

Select

Zip Code*

Physical Address

Street Address

City

State

Select

Zip Code

Are you receiving any of the following assistance?

You must provide documentation of assistance received to complete your application. Please check all that apply.

Select

Please upload your documentation of assistance you receive.

Drag and drop files here or

Names & Ages of Household Occupants:

Would you like to round up your bill to support OPALCO's Project Pal program?

Project Pal is annual one time support to help members pay their electric bill.

Yes

No

Member Signature

By entering your name you certify that all information provided is true and correct to the best of my knowledge. I understand that OPALCO reserves the right to reduce the amount of credit on my account based on available funding and direction from the Board of Directors. I am aware that any false information provided will disqualify my account for future assistance and any previous credits will be reversed, and subject to normal collection procedures. I understand that I must renew my application by April 30th of each year to continue receiving the bill credit.

Signature*

Signature Date*

VOLUNTARY Demographic Information

Why do we ask? This information helps us access grants and other funding opportunities to better serve you!

Veteran

Yes

No

Disabled?

Yes

No

Send me a copy of my responses

Mailing Address

Physical Address

Member Signature

**VOLUNTARY** Demographic Information

VOLUNTARY Demographic Information