Divernon, IL · Sangamon County
Energy Assistance Additional Forms
This packet contains supplementary energy assistance forms for applicants who need to document zero income or provide household and community needs information.
What this form is
The packet includes a Zero Income Affidavit for adults reporting no income, a community needs assessment survey, and participant characteristics questions. The affidavit asks about household members’ income and expenses and requires the applicant’s signature and date; the survey asks about household needs and says to return it where received. The packet also includes energy assistance program information and appeal rights.
Who needs it
Energy assistance applicants may need the zero-income affidavit if an adult household member reports no income, and may also complete the included survey.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This document is signed without a notary; the packet mentions a Verification of Paying Household Bills Affidavit as an additional step, but does not say it must be notarized.
How to submit this form
- 1
Download The Packet
Download the Energy Assistance Additional Forms PDF.
- 2
Complete The Relevant Forms
Answer the questions that apply, and sign and date the Zero Income Affidavit if completing it.
- 3
Gather Any Additional Forms
If someone else pays household bills directly, the affidavit instructs you to complete a Verification of Paying Household Bills Affidavit as well.
- 4
Submit The Forms
Return the survey where you received it; check the city website for current submission details for other forms.
Frequently asked questions
- What forms are included in this packet?
- The packet includes a Zero Income Affidavit, a community needs assessment survey, participant characteristics questions, and energy assistance program information.
- Who should complete the Zero Income Affidavit?
- The affidavit is for adults in the household reporting zero income. It asks about work payments, cash gifts, loans, and expenses paid directly by another person or agency.
- Do I need a notary for the Energy Assistance Additional Forms?
- No. This packet is signed without a notary. It mentions a Verification of Paying Household Bills Affidavit as an additional step but does not say that it must be notarized.
- How do I submit the survey?
- The survey instructions say to return it where you received it. For other forms in this packet, check the city website for current submission details.