Energy Assist Application Energy Assist OPALCO ACCOUNT #: * RequiredMember Name: * RequiredPhone Number:Email Address: * RequiredMailing Address * RequiredPhysical AddressAre you receiving any of the following assistance? You must provide documentation of assistance received to complete your application. Please check all that apply. Supplemental Nutrition Assistance Program (SNAP) Free/Reduced Lunch Program Apple Health (MEDICAID) Social Security Disability (SSDI) San Juan County Senior/Disabled Tax Exemption Program Low Income Home Energy Assistance Program (LIHEAP) Rental Assistance Other Utility Assistance Project PAL Other Please upload your documentation of assistance you receive. * RequiredNames & Ages of Household Occupants: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.