Income-based program application

Income-based program application

Fill out the information below to apply for a conversion grant from National Fuel’s Income-Based Conversion Program.

    Income-Based Gas Conversion Program Application

    Income eligible customers in National Fuel’s Western New York service territory may complete this application to apply for a grant to convert existing heating systems that use an alternative fuel source such as oil, propane, electric, wood, or coal to natural gas. Applicant must own and reside in the home or be a tenant who is responsible for the utility bills. If tenant is applying, the owner must complete the Income Property Owner Natural Gas Conversion Agreement.

    Section 1: Applicant Information

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    If different than Home Address

    Do you currently have a National Fuel Gas Account?*

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    Please choose one of the following:*

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    If you rent, please provide the owner’s information below:

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    Section 2: Primary Heating Fuel*

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    Section 3: Income Information

    Income information and documentation is required.

    1. Provide a copy of one of the following: entire HEAP award letter or documentation for all household gross income for the last 12 months (including but not limited to pay stubs, social security, disability, worker’s compensation, unemployment, and child support).*

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    2. Provide information on all household members. Provide all types of current gross annual income for all residents of the household, age 18 and over, who are not full-time students. If listing income from self-employment, business, rental, or farming income, list the net income after operating expenses. Please use additional pages, if needed.
    Name* Age* Student (Y/N)* Source of Income* Weekly* Monthly* Yearly*

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    Add Household Member

    Total Income for the Household

    Weekly Total* Monthly Total* Yearly Total*

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    Eligibility

    My signature below certifies that the information I have provided is true and correct. I hereby consent and authorize the above utility and other fuel suppliers to release any and all of my energy consumption information, including account number(s), to National Fuel and its administrator.

    I authorize the release of my contact information and income documentation to National Fuel and/or its designated representatives for the purpose of determining my eligibility for the Income-Based Gas Conversion Program. I understand that such information will be kept confidential, to the extent permitted by law, and will be used only for determining program eligibility or participation in other National Fuel low programs and assistance.

    I understand that program eligibility is based upon income and other requirements. Grants are provided based on the number of applications received and availability of funds, and my receipt of program benefits is not guaranteed.

    I understand that if I am approved for the program, I will not be responsible for any costs (typically up to $6,000) for the conversion of my current heating system, and water heating system (if applicable), to natural gas. If there are costs of natural gas conversion that will exceed the amount to be paid by National Fuel’s grant, I understand that I will be provided with a cost itemization breakdown from my contractor and will need to sign it and agreeing to pay the amount not covered by National Fuel’s conversion grant. I also understand that National Fuel will pay all conversion grant funds directly to the contractor who completes the work, and not to me.

    I will cooperate and permit National Fuel representatives, independent contractors and agents to access my dwelling, pipes and equipment, at times which are mutually acceptable, for performance of all activities to successfully permit conversion of piping and equipment to natural gas. This also includes the performance of quality assurance activities following completion of the conversion work. Photos may be taken of the work performed.

    I understand that neither National Fuel nor its program administrator are responsible for the installation of new natural gas appliances or for warranties. I also understand that I am responsible for any costs associated with maintenance of the installed equipment.

    In consideration of conversion grant amounts provided by National Fuel without charge to me, to the extent permitted by law, I agree to indemnify, hold harmless, release and waive any and all claims against National Fuel and/or its administrator with respect to any loss, claims, actions or liability that relate to or arise out of the natural gas conversion work or program, or events or activities involved with any National Fuel programs or assistance.

    If I am a tenant, I understand that the owner must complete the Income Property Owner Gas Conversion Agreement for the program and agree to contribute 25% of the project costs, unless the premises is owner occupied and the owner also qualifies for the program.

    I understand that I must be currently heating my home with a fuel source other than natural gas in order to qualify for the natural gas conversion program. Any false information provided can result in denial of my application. I understand that National Fuel reserves the right to deny my application for any reason.

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    Completed applications and supporting documentation can be mailed to:

    CJ Brown Energy, Attn: Low Income Conversion

    4245 Union Road, Suite 204

    Buffalo, NY 14225

    (if applicable)

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