Member Assistance Program Application

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Salem Electric members who meet income guidelines may qualify for a bill credit. Assistance is available once per year, subject to program funding.

Applicant Information

Enter your Account #

First Name

Last Name

Last four digits of SSN

Service Address Street

City

State

Use two letter abbreviation

Zip Code

Phone

Application Record Type ID

Record Type Name

Service Location Information

Property Type

Housing Category

Source of Heat

If other...

Household Members

Please list all household members including the applicant. Proof of income for the last three months must be provided for ALL household members. Incomplete applications will be returned.

Number of members in the household

Person 1

Name

Age

*Gross Monthly Income

Source of Income

Proof of Income

Person 2

Name

Age

*Gross Monthly Income

Source of Income

Proof of Income

Person 3

Name

Age

*Gross Monthly Income

Source of Income

Proof of Income

Person 4

Name

Age

*Gross Monthly Income

Source of Income

Proof of Income

Person 5

Name

Age

*Gross Monthly Income

Source of Income

Proof of Income

Person 6

Name

Age

*Gross Monthly Income

Source of Income

Proof of Income

Person 7

Name

Age

*Gross Monthly Income

Source of Income

Person 8

Name

Age

*Gross Monthly Income

Source of Income

If no household income, explain here:

Electronic Signatures. The parties agree that this Application may be executed and delivered by electronic signatures and that the signatures appearing on this Application are the same as handwritten signatures for the purposes of validity, enforceability and admissibility. If you do not consent to the foregoing, do not click “Submit” and contact Salem Electric for alternative method of document execution.

Please sign here