Energy Affordability Program Application

Account Name:

Benefit Qualifying Person (if different than customer):

Mailing Address:

Apartment Number:

City / Town:

State:

Zip Code:

Phone Number:

Email Address:

Account Number:

Eligibility Requirements

To prove participation in one of the above programs, customers must submit an award letter or a document that includes their name or the name of their benefit qualifying person (BQP), the name of the qualifying program, and the government, Tribal entity or program administrator that issued the document. All documentation must have an issue date within the last 12 months or a future expiration date that aligns with the benefit period.

Upload Documentation:

Customer/Benefit Qualifying Person Certification and Authorization

(If Customer is applying based on BQP’s enrollment in a qualifying program, both Customer and BQP must sign below.)

I certify that the information above is correct. By signing this form, I allow Central Hudson Gas & Electric to share and verify information in my application or documentation for this program with Third Parties. I also allow Third Parties to give Central Hudson Gas & Electric, or representatives or agencies of the federal, state, or local government, information or documentation requested about me related to this and related programs. This information will be shared to help process my application and for ongoing participation and compliance with the program. Information that Central Hudson Gas & Electric and a Third Party may share about me:

Information about my application, program participation, and eligibility. Information and documentation about utilities, payment history, employment history, income, application status, and award information for benefits or utilities assistance.

Customer Signature (type your name to sign):

Date:

Benefit Qualifying Person Signature (if necessary):

Date:

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Energy Affordability Program Application

Discount for eligible residential customers

Eligibility Requirements

Customer/Benefit Qualifying Person Certification and Authorization