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2. Program Qualifications.

   To qualify, the total household income must be at or below 200% of the Federal Poverty Level and shall not exceed the amounts shown on the Utility Assistance Program page. Examples of income qualifying documentation would be current SNAP or OHP documentation.

4. First Name*
5. Last Name*
7. Service Location Address*
9. City*
10. State
11. Zip Code
13. Email Address*
14. Phone Number*
16. Utility Account Number*
17. Number of People in Household*
19. Income qualified program you are applying for:

    1. Electric Vehicle
    2. Heat Pump Space Heater (mini split or forced air)
    3. Heat Pump Water Heater
    4. Rental Unit - Packaged Terminal Heat Pump (PTHP)
    5. Electric Ready Panel or Circuit Upgrade
    6. Other (list in comment box below)

    This is not the form to use for utility assistance program. That form is linked on its own page. 

21. Comments:
23. Income Verification Document 1
24. Income Verification Document 2
25. Income Verification Document 3
26. Income Verification Document 4

30. Information you provide is material to your eligibility for receiving a benefit. Therefore, giving false or misleading answers in this application to obtain a discount on your utilities is a crime, punishable up to 6 months jail and/or $2,500 fine. (ORS 162.085).

    I hereby request the income qualified incentive multiplier and have provided the City of Ashland with income verification documentation for all members of the household above the age of 16 by redacting secure information and uploading documents above.

    I certify that the above information is true to the best of my knowledge.

32. Signature of Applicant (Type Name)*
33. Date*
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field