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Intake-assigned COR Rep
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Utility Information
Home Details
Qualification Options
Income Qualification
No Income Affidavit
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We've copied this for you, only change if necessary. This name should match the applicant and the account holder.
Affidavit for Household with No Income:
I affirm that no adult over
the age of 18 years, listed above, who lives in my household, has had any income in the four
weeks prior to the date this affidavit is signed below. This means no adult in my household
and is listed below has received income from employment, a pension, unemployment or
worker's compensation, cash assistance from the Connecticut Department of Social Services
(Temporary Family Assistance, State Supplement or the State Administered General
Assistance program), benefits from the Social Security or Veteran's Administration, child
support, alimony, interest, or any other income source.
The following people live in my household and have no income:
I understand that the HES-IE program may request supporting documentation regarding my
income. I affirm that the information indicated on this form is accurate. I understand that if the
information is not correct, I may be charged for the energy efficiency services I am provided
by the HES-IE program.
Landlord Rental Income
This form is for applicants who also earn income as landlords/property owners.
Property Owner Authorization
Earlier, you indicated that you rent your home. We will need to get authorization from your landlord. Please fill the section below.
I am the Property Owner but not the Applicant and I authorize
Eversource and United Illuminating (Utilities) and their authorized
vendors and agents to perform the Initial Visit on the Property, provide
the Applicant with Home Energy Solutions - Income Eligible services
that Applicant requests for the Property at no cost to me and provide
verification services to confirm proper install
THIS FIELD HAS BEEN FILLED BY YOUR LANDLORD.
Applicant Authorization
I am the Applicant that has completed this Application. I request Home Energy Solutions - Income Eligible services for the Property above. I understand if qualified that the initial visit will be provided at no cost to me. I authorize Eversource and United Illuminating (Utilities) and their authorized vendors and agents to enter my Property to perform the Initial Visit, provide me with Home Energy Solutions - Income Eligible services and verification services to confirm proper install.