Cold Weather Income Verification Application

MVEC Members with a household income at or below 50% percent of the state median household income are eligible to avoid disconnection of their electric service between October 1 and April 30 if they enter into a payment arrangement and make timely payments per the agreement. To request an arrangement, please fill out and return this form to MVEC at least 5 days prior to your disconnection date.

If MVEC accepts your Income Verification Form, and you make the required monthly payment, we cannot disconnect your electricity between October 1 and April 30.

MVEC complies with the Federal Trade Commission’s Red Flag rule, which helps detect, prevent and mitigate damage caused by identity theft. MVEC reserves the right to ask questions to help validate the identity of an account holder when changes to an account are requested by phone or in person.

Contact Information

Account Number

Date of Birth

First Name

Last Name

Primary Phone

Work Phone

Email Address

Confirm Email Address

Address

Address Line 1

Address Line 2

City

State

Zip Code

Account Information

Last 4 Social Security Numbers

Total annual household income

Number of persons in household (including yourself)

Proof of Need

This agreement REQUIRES PROOF of need. Please attach copies of documented proof that you may have for any persons in the household. Examples include:

Please explain any other proof of need:

Uploads

Scan or photograph supporting documentation and upload here

NOTE: Applications without copies of your income information are incomplete and may not receive protection from shut off. This is a declaration of my inability to pay for heat during cold weather.

This is a declaration of my inability to pay for heat during cold weather months. I’m willing to make payment arrangements, approved by MVEC. By signing this form, I hereby authorize any gas or electric utility that serves us to exchange billing information. I attest the above information is true and correct, and agree to abide by the terms of the payment arrangement.

Signature (type your full name)

Date

To ensure an actual person is filling out the form, please answer the following question: 6 + 2 =

If you do not wish to submit this form online or are unable to attach your supporting income documentation, you can print and mail or fax this application to: Minnesota Valley Electric Cooperative ATTN: Collections 125 Minnesota Valley Electric Drive | Jordan, MN 55352 Fax: 952.492.8281 Email: info@mvec.net

Contact Information