Home Energy Solutions Program                  Customer Interest Form 2009
Due to potential high customer participation and program oversubscription, we reserve the right to restrict services to homes
that could benefit the most. This program is subject to change based on available funding.  Currently there is a $ 75 fee for all customers.
If your home is selected, you will be notified via letter or telephone.  FILLING OUT THIS FORM DOES NOT GUARANTEE ACCEPTANCE.
An authorized adult must be present during the assessment and provide access to the premises.
 

(Please Print) First Name      Last Name 
Address 
Unit #
City State   Zip Daytime Telephone Number  
Utility Account Number:     Electric: CL&P  OR UI        Natural Gas
                                                                                                                                 CNG   or   SCG   or   YANKEE GAS (please BOLD)

Residence Type:  all that apply:  Apartment   Single Family   Condo   Duplex   Year Round   Seasonal Use only 

Do You:  Rent or Own (Please BOLD)  Renters:  Please have your landlord complete and sign this section

I am the owner or authorized agent of the residential building(s) located at:
I hereby give permission to the following utility companies: CL&P, CNG, Yankee Gas, UI or SCG, or their authorized agents, to perform an energy
conservation needs assessment and to install energy-efficient measures at the above-referenced location at no cost to me.
Print Name:  Signature:   Date: 
Average Monthly Utility Bill:   Electric   Gas 
Age of Home: Years          Heated Square Footage of Home   Sq Ft
Central Air Conditioning

Age of Central A/C: Years

Primary Heat Type   Electric             Forced Hot Air            Hot Water Baseboard       Other    please type   
Do you have an oil, propane or kerosene heating service contract? (please BOLD)          Yes          No

Primary Fuel Type:   Electric          Gas            Oil            Propane         Other  please type 
Hot Water Type:      Electric          Gas            Oil            Propane         Other
To determine if you are eligible for additional services, please BOLD the appropriate box:
Total gross household income:)  $0-$30,000   $31,000-$50,000   $51,000-$70,000   Over $70,000
How many individuals live in your home? 
How did you hear about the HES program?:   Bill Insert     Direct Mail     Radio/TV    Other
Have you participated in any in-home utility conservation programs within the past 18 months? (please BOLD):  Yes    No
(Please Describe)
Connecticut's Energy Efficiency Programs are funded by a Charge on Customer energy bills.
The Programs are designed to help customers manage their energy usage and cost.

Please return completed form to:     Save Home Energy, Inc.    1082 Farmington Avenue    Kensington, Ct.  06037

Also, save the form and attach to an email to:  savehomeenergy@yahoo.com or Fax 860-829-9991.

Thank You