CEC Account Number:
Member Phone Number:
1. Did you qualify and receive energy assistance during the 2019-2020 heating season?
If you did receive energy assistance during the 2019-2020 heating season, what was the name of the utility that received the funds?
If you did receive energy assistance during the 2019-2020 heating season, how much assistance did you receive? Include regular and crisis funds.
If you did not receive money from energy assistance, what is the reason why you did not?
If you selected other above. Please explain here.
2. Are you or have you, or any other adult living in your household, been out of work, for any reason, due to COVID-19?
If you answered yes to question 2, what is the name of the person who was out of work?
If you answered yes to question 2, what is the name of that person's employer?
If you answered yes to question 2, what is the phone number for that person's employer?
3. What is the balance due on your CEC account?
4. What was the date and amount of the last payment you made on your CEC account?
5. In the past three years how many times have you received a disconnection notice from CEC?
6. If you have received a disconnection notice in the past, was your electric service disconnected as a result?
7. How many years have you been a member of CEC?
8. Please briefly explain your situation and why you need the grant to provide help with paying your CEC electric bill?
By checking this box you declare that all of the information provided on this application is true and accurate to the best of your knowledge. You understand that misrepresentations or incorrect information provided to CEC will result in application denial
Member Full Name:
By checking this box you are marking this application as signed.
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CEC reserves the right to require additional documentation in order to qualify.
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