Section 1: Applicant Information
CMP Account Number (no dashes)
Date entered (MM/DD/YYYY)
Applicant's first name
Applicant's last name
Applicant's email address
Application date (MM/DD/YYYY)
Select a State
Armed Forces Africa
Armed Forces Americas
Armed Forces Canada
Armed Forces Europe
Armed Forces Middle East
Armed Forces Pacific
District of Columbia
Federated States Of Micronesia
Northern Mariana Islands
Phone number where you can be reached
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):
Room Air Purifier
Air Conditioner (central)
Top Load Clothes Washer
Air Conditioner (window)
Cook Stove / Oven
Electric Heat Tape
Other (list below)
2. Approximately how many screw-in lights currently use efficient bulbs, either LEDs or CFLs (curly)?
More than 10-20
All or Nearly All
3. Has the applicant participated in any Efficiency Maine or MSHA weatherization programs?
If yes, please list program(s) and participation date(s)
4. Does the applicant own or rent their home?
5. Type of residence
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.
Check box below