Eversource is offering free weatherization services

Dear Valued Customer:
Eversource is offering free weatherization services designed to lower your energy bill.
The HES-IE program is available to renters or homeowners with a GROSS income at or
below 60 percent of the state median income. You may receive energy-saving compact
fluorescent lightbulbs (CFLs), caulking, weather stripping and much more.
Please complete all pages and return to us via mail. Our address: Home Energy
Solutions – Income Eligible, Eversource, P.O. Box 270, Hartford, CT 06101-9902.
Remember, if you rent, your landlord must complete the Owners Permission Statement.
Your verification of income must be submitted along with the application. Also, please
be sure to check each box on the form so your application can be processed without
delay.
Sincerely,
The Energy Efficiency Team
Eversource
Respetable Cliente:
La compañia Eversource esta ofreciendo servicios gratis de aclimatacion diseñados
para ayudarle a reducer sus cuentas de energia. El Programa HES-IE esta disponible
para inquilinos ó dueños con ingresos brutos al 60 porciento ó menos del promedio de
ingresos del estado. Puede recibir bombillas fluorescente que ahorran energia,
calafatee, burlete y mucho mas.
Complete por favor todas las paginas y envielas a nuestro correo postal: Home Energy
Solutions – Income Eligible, Eversource, P.O. Box 270, Hartford, CT
06101-9902.
Recuerde, si usted alquila, su propietario tiene que completer la Declaracion de Permiso
de Propietarios. Su verificacion de ingreso debe ser sometido juntamente con la
solicitud. Tambien asegure de reviser cada seccion de la solicitud para que sea
procesada sin demoras.
Sinceramente,
The Energy Efficiency Team
Connecticut Light & Power Company
Referring Agency: Wesson Energy, Inc
165 Railroad Hill St., Waterbury, CT 06708
203-759-3800
Application for FREE HES-IE Services
READ AND COMPLETE ENTIRE FORM
CR6338-1 REV. 7-14
Name/Nombre
Address/Direccion
City/Ciudad
State/Estado
Telephone Number/Numero de Telefono
Zip Code/Codigo Postal
Email/Correo Electronico
Best Time To Call/Mejor Hora Para Llamar:
Morning
Home total sq. ft. /Total en pies cuadrados:
Afternoon
Evening
Total heated sq. ft./Pies cuadrado con calefaccion:
PLEASE COMPLETE ALL THAT APPLY:
EVERSOURCE ELECTRIC ACCOUNT NO.
EVERSOURCE GAS ACCOUNT NO.
OIL COMP. NAME & ACCT NO.
CNG ACCOUNT NO
SCG ACCOUNT NO.
PLEASE ANSWER ALL QUESTIONS BELOW. ALL INFORMATION IS STRICTLY CONFIDENTIAL
1. I am a/Soy:
Homeowner/Dueño
Tenant/Inquilino
7. My heating source is: (check only one)
Oil
If you rent, you must print your landlord's/agent's name and
address below. LANDLORD/AGENT MUST SIGN ATTACHED
PERMISSION STATEMENT.
Electric
Gas
Propane
Name
Solar
Address
8. My water is heated by: (check only one)
City
State
Zip Code
Oil
Electric
Gas
2. Household information/Informacion de Casa:
Propane
Solar
Total # of people in household:
Num. of children/niños:
9. My heating system type: (check only one)
Num. of elderly/anciano:
Num. of disabled/incapacitado:
Hydro Air
3. The total GROSS monthly income of all members in my household:
Ingreso Total Mensual
$
Baseboard/Radiant
Geothermal
Furnace
Heat Pump
You are required to provide documentation to substantiate
Boiler
your income. Documentation may include pay stubs, social
10. My cooling system type: (check only one)
security check receipts and pension slips. CL&P reserves
the right to verify income before services are provided.
Central AC
4. My source of income is from: (check all that apply)
PTAC
Heat Pump
Wages/Sueldo
Other
Window AC
State Assistance
None
Social Security/SSI
I understand there will be no cost to me or my landlord/agent
5. Received State Energy Assistance (provide copy of award letter):
to receive these free weatherization services. I authorize
Recibio Asistencia de Energia Estatal (incluya copia de la carta)
Yes
my gas/oil company to release usage information to Eversource and its
No
agents. I affirm that the information in this form is accurate.
I understand that if the information is not correct, I may be
6. I live in a: (check one only)
charged for the conservation assistance I am provided by the
Single Family
2-4 Units
Townhouse/Rowhouse
5 + Units
Mobilehome
Condo
For Office Use Only
WO#/Date/Initials:
HES-IE program.
Please sign below:
Signature/Firma:
Date/Fecha:
Owner’s Permission Statement
Free HES-IE Weatherization Services
I am the owner or authorized agent of the residential building(s) located at:
I hereby give permission to the following utility companies: Eversource and
Connecticut Natural Gas (CNG), or their authorized agents, to perform an energy
conservation needs assessment and to install energy conservation measures
at the above referenced location at no cost to me.
Owner/Agent
Address
City, State, Zip
Telephone
Signature
Print Name
Date
E-mail
Authorized agents include the utility administrator, Community Action Agency
weatherization department, or contractor hired to install conservation
measures.
Please return this form in the postage-paid envelope enclosed with the
application or mail to:
HES-IE Weatherization Services
Eversource
PO Box 270
Hartford, CT 06101-9902
Referring Agency: Wesson Energy, Inc
165 Railroad Hill St., Waterbury, CT 06708
203-759-3800
Referring Agency: Wesson Energy, Inc
165 Railroad Hill St., Waterbury, CT 06708
203-759-3800
HES-IE Weatherization Application Instructions
Thank you for your interest in the HES IE Weatherization program. Your application can only be
processed if you include your income verification. If you do not submit the necessary documents;
application, income verification and property owner statement (if needed), your application approval will be
delayed until all documents are received and reviewed.
The person that is completing and signing the application must be the individual that is the electric or
gas account holder with Eversource and or CNG/SCG.
The application must be entirely completed to prevent it from being returned for additional
information. Please pay close attention to the following items:

Application:
a. You must include your Eversource electric account number
b. If you have a natural gas account you must provide your account number. This will be for
either Eversource, CNG, or SCG
c. Owner’s Permission Statement must be signed and dated by the owner of the property
d. Total household number includes all people who live in the house and income information
must include each person age 18 or over.
e. Signature of Electric/Natural Gas Account Holder is required. If you are not the account
holder please do not sign the application. Unauthorized applicant signatures will
not be accepted and application will be returned.

Zero income affidavit:
a. – Must be completed listing anyone over 18 with zero income

Total Gross Income – Supporting Documentation must be included
a. Copy of most recent Pay Stubs for one month (Weekly/BiWeekly)
b. Previous Year Income Tax copy of 1040
c. Pension/Retirement Check Stub
d. If you are receiving Social Security and or SSI a photocopy of your award letter is
required
e. If you are receiving State Supplement Income/EBT a photocopy of your EBT card is
required
f. If you received energy assistance provide a copy of your energy assistant acceptance
letter
Referring Agency: Wesson Energy, Inc
165 Railroad Hill St., Waterbury, CT 06708
203-759-3800
HES-IE Instrucciones para Completar la Solicitud
Gracias por su interés en el programa HES-IE. La solicitud sólo puede ser procesada si incluye la
verificación de ingresos. Si no presentan los documentos necesarios: solicitud, verificación de ingresos y
la declaración de permiso del dueño de la propiedad (si es aplicable), su aprobación de la solicitud será
retrasada hasta que todos los documentos sean recibidos y revisados.
La persona que firma la solicitud debe ser la persona que tiene la cuenta de gas o de electricidad con
Eversource y/o CNG/SCG.
La solicitud debe ser sometida por completo para evitar que se devuelva por falta de información. Por
favor, preste atención a lo siguiente:
Solicitud:
a. Debe incluir su número de cuenta eléctrica de Eversource.
b. Si tiene una cuenta de gas natural debe proveer su número de cuenta. Esto será para
Eversource, CNG y/o SCG
c. La Declaración de Permiso Del Dueño debe ser firmada y fechada por el dueño de la
propiedad
d. El número total de toda la gente que vive en la casa y la información de ingresos debe
ser incluida para cada persona de edad de 18 o más.
e. Se requiere la firma de la persona que tiene la cuenta eléctrica o gas. Si no es el titular
de la cuenta por favor no firme la solicitud. Las firmas no autorizadas no serán aceptadas
y la solicitud será devuelta.
Declaración jurada de cero ingresos:
a. Debe ser completado con los nombres de toda persona de 18 años o más con cero
ingresos.
Documentos que demuestran el total de ingreso bruto:
a. Un mes de los más recientes recibos de sueldo (Semanal o Cada dos semanas)
b. Copia del formulario 1040 impuesto del año anterior
c. Talón de cheque de la pensión o Retiro
d. Si recibe Seguro Social y/o SSI se requiere una fotocopia de su carta
e. Si recibe el Suplemento Estatal /EBT se requiere una fotocopia de su tarjeta EBT
f. Si recibió asistencia de energía se requiere una copia de su carta de aceptación
Referring Agency: Wesson Energy, Inc
165 Railroad Hill St., Waterbury, CT 06708
203-759-3800
Affidavit of Household With No Income
Home Energy Solutions - Income Eligible Program (HES-IE)
I,
, affirm that no one over the age of 18 years who
lives in my household, has had any income in the four weeks before the date I signed this
affidavit. This means no adult in my household has received income from work, 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, interest, or any other income source.
The following people live in my household:
Name
Check if person is under 18 years old
□
□
□
□
I understand that the HES-IE program may request documentation regarding my income.
I affirm that the information in this form is accurate. I understand that if the information is not
correct, I may be charged for the conservation assistance I am provided by the HES-IE program.
Name:
Date:
Phone number:
Energize Connecticut – programs funded by a
charge on customer energy bills
Referring Agency: Wesson Energy, Inc
165 Railroad Hill St., Waterbury, CT 06708
203-759-3800
Declaración Jurada de Familia Sin Ingresos
Soluciones de Energía Para El Hogar - Programa de Ingresos Elegibles (HES-IE)
Yo, _______________________________________ afirmo que nadie sobre la edad de 18 años que vive en mi
casa, ha tenido algún ingreso en las cuatro semanas antes de la fecha firmada en esta declaración jurada.
Esto significa que ningún adulto en mi hogar ha recibido ingresos de trabajo, una pensión, desempleo o
compensación del trabajador, asistencia en efectivo del Departamento de Servicios Sociales de Connecticut
(asistencia de familia temporal, suplemento estatal o el programa estatal de asistencia general), beneficios del
Seguro Social o de veteranos, manutención, interés o cualquier otra fuente de ingresos.
Las siguientes personas viven en mi casa:
Nombre
Verifique si la persona es menor de 18 años de edad
□
□
□
□
Yo entiendo que el programa HES-IE puede solicitar documentación sobre mis ingresos.
Afirmo que la información contenida en este formulario es correcta. Entiendo que si la información no es
correcta, me pueden cobrar la asistencia de conservación recibida por el programa de HES-IE.
Nombre:
La fecha:
Teléfono:
Energize Connecticut – programs funded by a
charge on customer energy bills

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