Apply for Project Helping Hand Assistance

Comments

This field is for validation purposes and should be left unchanged.

Have you been approved for a Project Helping Hand donation in the past 12 months?*

Yes
No

We appreciate you attempting to apply for the CEC Project Helping Hand Program. You answered yes to the question of: Have you been approved for a Project Helping Hand donation in the past 12 months?

Members approved for Project Helping Hand assistance are not eligible to apply again for the next 12 consecutive months. If you are interested in alternative assistance opportunities, please visit the Community Assistance section of our website.

If you have further questions, please contact our office at 541-548-2144, to speak with a Customer Service Representative.

Have you submitted a Project Helping Hand application that is in the process?*

Yes
No

Application processing may take up to two weeks. If you have submitted an application in the past 12 months which was not approved, and would like to be considered again, please select 'No' and complete the application again.

Please allow up to two weeks for processing. If you have questions about the status of an existing application, please contact our office at 541-548-2144 to speak with a Customer Service Representative.

Applicant Name*

First MI Last

Applicant Date of Birth (MM/DD/YYYY)*

Co-Applicant Name

First MI Last

Co-Applicant Date of Birth (MM/DD/YYYY)

Other Occupant 1 Name

First MI Last

Other Occupant 1 Date of Birth (MM/DD/YYYY)

Other Occupant 2 Name

First MI Last

Other Occupant 2 Date of Birth (MM/DD/YYYY)

Other Occupant 3 Name

First MI Last

Other Occupant 3 Date of Birth (MM/DD/YYYY)

Other Occupant 4 Name

First MI Last

Other Occupant 4 Date of Birth (MM/DD/YYYY)

Account Number:*

Your CEC account number can be found on your monthly statement, or call Customer Service at 541-548-2144.

Service Address*

Street Address Address Line 2 City ZIP Code

Phone*

Email:

Are any occupants in the household currently employed?*

Yes
No

Applicant Employer

Applicant Annual Income

Please enter a number less than or equal to 999999.

Co-Applicant Employer

Co-Applicant Annual Income

Please enter a number less than or equal to 999999.

Annual Unreimbursed Medical Expenses

Please enter a number less than or equal to 999999.

Type of Heat Source*

Medical Necessity Certificate Approved & Filed with CEC?*

Yes
No

If no, are you submitting a medical necessity with this application?

Yes
No

Alternate Assistance Received

Reason for application:*

This is a situationally based program, so please elaborate.

Disclaimer and Release

CEC does not discriminate on the basis of race, color, religion (creed), gender, gender expressions, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in administering the Project Helping Hand program (Program). We are committed to providing an inclusive and welcoming environment for all members. I have voluntarily agreed to apply for assistance under this Program. I understand that I must provide all information required by CEC and the information I provide will be used to determine and verify my eligibility for this Program. I hereby authorize CEC to verify the information on this application. I acknowledge that, based upon such information and other factors, which may apply, CEC may in its sole discretion either grant or deny me assistance under this Program. I certify that the information I provided to complete this application is true and correct and that any Program funds received by me will be used solely for the purpose of paying my energy costs. I agree to release, indemnify, and hold harmless CEC and its directors, officers, employees and contractors from and against all claims, damages, losses, suits, judgements, costs or expenses (including reasonable attorney fees) incurred by CEC and arising from, or in connection with the processing and review of this application and the administration of the Program.

I acknowledge that I am the account holder or the customer’s authorized agent for the utility account(s) identified in this application and that I am authorized to submit this application.

By checking this box and typing my name, I certify that all information on this form is true and correct. I also agree that the checkbox and my name typed below are to be used as my electronic signature. I understand that I can be held liable if I provide false or misleading information.

Type Full Name*

Consent*

I agree to the privacy policy in the link below:

CEC Privacy Policy

Project Helping Hand Assistance Application

Disclaimer and Release