Ohop Mutual State HEAR Program Residential Customer Application

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Applicant Information

Name(Required)

First Last

Account #(Required)

Email Address(Required)

Phone Number(Required)

Service Address(Required)

Street Address

Other Household Members

Name

Relationship

18+ Years Old (Y/N)

Gross Monthly Income

Email Address

All Household Members 18 years of age or older must list monthly income. Those household members 18 + with NO income must provide a signed attestation of zero income including an explanation of the no-income-status (student, lost job, no unemployment compensation).

Total Household Members (All Ages)(Required)

Total Gross Monthly Income for ALL Household Members(Required)

Property Information

Building Type(Required)

Occupancy Status(Required)

Owner Occupied

Renter Occupied

Rental Property Owner Agreement

Notice: The Ohop Mutual Light Company (OMLC) State Home Electrification and Appliance Rebates (HEAR) Program may provide incentives for eligible energy improvements in rental properties occupied by eligible tenants. As a condition of participation, property owners receiving the benefit of State HEAR-funded improvements must agree to certain conditions outlined in the “Rental Property Owner Agreement.” The agreement is intended to protect tenants while supporting investments in high-efficiency electric equipment and building electrification.

Name(Required)

First Last

Property Owner

Phone(Required)

Property Owner

Existing Heating Equipment

Primary Heating Fuel(Required)

Existing Heating System(Required)

Existing Water Heating Fuel(Required)

Proposed Project

Please check all that apply.

Heating & Cooling

Ductless Heat Pump

Ducted Heat Pump

Ground Source Heat Pump

Water Heating

Heat Pump Water Heater

Electrical Upgrades

Panel Upgrade

Service Upgrade

Wiring Upgrade

Appliances

Heat Pump Dryer

Induction Range

Induction Cooktop

Other Eligible Equipment

Priority Population Information

Please check all that apply.

Priority Population Information(Required)

None Apply

Participant in LIHEAP

Participant in SNAP

Participant in Medicaid

Participant in SSI

Operation Round Up recipient

Senior Discount participant

Manufactured Home Resident

Disabled Veteran Household

Medically Vulnerable Household

Program Eligibility

Pathway A – Categorical Eligibility(Required)

None Apply

LIHEAP

SNAP

Medicaid

SSI

WIC

Weatherization Assistance Program

HOMES Program

HARP Program

Applicant participates in an approved income-qualified program.

Categorical Eligibility Verification

Applicant must provide proof of categorical eligibility. Example: Benefit Statement.

Upload Categorical Eligibility Verification

Drop files here or

Max. file size: 32 MB, Max. files: 3.

All uploads are encrypted, however, you may bring proof of income to the office instead.

Income Verification

Applicant must provide proof of income.

Pathway B – Income Documentation(Required)

Federal Tax Return(s)

W-2 Form(s)

Pay Stub(s)

Social Security Benefit Statement(s)

Pension Statement(s)

Unemployment Benefits Statement(s)

Other

Upload Income Verification

Drop files here or

Max. file size: 32 MB, Max. files: 3.

All uploads are encrypted, however, you may bring proof of income to the office instead.

Contractor Selection

Have you selected a contractor?(Required)

Yes

Contractor Name(Required)

Contractor

Phone(Required)

Contractor

Email(Required)

Contractor

Applicant Certification

Certification(Required)

I certify that:
• The information provided in this application is true and correct to the best of my knowledge.
• The property identified in this application is located within OMLC’s service territory.
• I understand that submission of this application does not guarantee funding.
• I agree to provide additional information if requested.
• I understand that OMLC may audit this application and supporting documentation.

Program Review and Audit Acknowledgement(Required)

I acknowledge and agree to these requirements.

• OMLC is required to conduct program monitoring, quality assurance reviews, and audits.
• My project may be selected for review or audit.
• If selected, I may be asked to provide documentation related to eligibility, project completion, invoices, permits, and other information necessary to verify compliance with Program requirements.
• Failure to provide requested documentation may affect eligibility for program funding.

Consent

I authorize OMLC to contact me regarding additional energy assistance, conservation, electrification, or income-qualified programs.

Typed Signature of Primary Applicant(Required)

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