Application for participation in the State of Maine's Arrearage Management Program
Section 1: Applicant Information
*CMP Account number(please enter without dashes or spaces):
Date entered (MM/DD/YYYY):
Applicant's name (first and last):
Applicant's email address:
Application date (MM/DD/YYYY):
Applicant's mailing address:
Service address(if different from mailing address):
Applicant participating in LIHEAP?
Electronic Signature of person applying:
Electronic signature of person filling out this form:
Section 2: Applicant's Heating Use
Primary area heating source(electric, oil, wood, etc)
Hot water heater fuel type(electric, gas, etc)
Age of electric hot water heater
1. Quantity of electric appliances currently in use (check all that apply):
2. Approximately how many screw-in lights currently use efficient bulbs, either LEDs or CFLs (curly)?
Please SelectNoneA FewMore than 10-20All or Nearly All
3. Has the applicant participated in any Efficiency Maine or MSHA weatherization programs?Please SelectYesNo
If yes, please list program(s) and participation date(s)
4. Does the applicant own or rent their home? Please Selectownrent
5. Type of residence:Please SelectApt/CondoSingle FamilyMobile
6. How many occupants live in the unit?
By signing this application, I: 1) certify that I am eligible for LIHEAP; 2) request that my electric utility enroll me in its Arrearage Management Program; 3) agree to abide by the terms of the Arrearage Management Program and understand that failure to do so may result in my removal from the program; 4) give my electric utility permission to share all electricity usage data from my residence including the information in this form with the Efficiency Maine Trust; and 5) agree to complete an electricity usage assessment with the Efficiency Maine Trust and understand that my failure to do so will result in my disqualification from the Arrearage Management Program.