2024 Income Eligibility Application

Focus Employee Completing Screen*

Focus Employee Email*

example@example.com

Notes

Documents Provided?*

YesNoPhone ScreenIQ Code Generation - IRA/Pilot Only

Zendesk Ticket Number:

Choose Documents Provided:*

How many 1040's are included?

This Income Eligibility Program application is for Focus on Energy rebates only. If you are interested in pursuing Inflation Reduction Act (IRA) Home Energy Rebates, you will be required to apply through the IRA income qualification process. Please visit the IRA Home Energy Rebates page to complete the IRA income qualification process.

Important Note: Approval for the Focus rebates will not qualify you for IRA rebates. However, approval for the IRA rebates will also include approval for Focus rebates.

What Income Eligibility Program are you applying for?*

Focus on EnergyIRA Home Energy RebatesBoth

To qualify for Inflation Reduction Act (IRA) click the link below to start your application. Your approval for the IRA rebates will also include approval for Focus if you meet the low income requirements.

IRA Home Energy Rebates

Fields with an * are required.

Head of Household:*

First NameLast Name

Phone Number:*

Please enter a valid phone number.

Customer Email:

example@example.com

Electric Utility Provider:*

Natural Gas Utility Provider:*

Residential Address:*

Street Address

Street Address Line 2

CityState

ZIP Code

County of Residence:*

Use Alternative Mailing Address

Mailing Address:*

Street Address

Street Address Line 2

CityState

Zip Code

Relationship to Address:*

Landlord Name:*

First NameLast Name

Landlord Phone Number*

Please enter a valid phone number.

Landlord Email Address:

example@example.com

Who Will Pay for Improvements?

If rebates are directly requested by tenants, written permission from the landlord/building owner, or authorized agent for the home efficiency project must be obtained before commencing work.

Household Income Limit Calculation

Household Income Limit is Based on Household Size and County

Is Anyone in Your Household Enrolled in Any of the Below Services?*

How many people live in your house?*

Include Head of Household

Annual Household Income Limit:

Not sure what your household’s annual income is? Check your latest tax filing or add up the last two months of pay statements for your household members and multiply the amount by six. Compare this number to the Annual Household Income Limit above to see if you qualify.

County

HH1

HH2

HH3

HH4

HH5

HH6

HH7

HH8

Household Income to Limit

Fill in the Below Table Based on Page 1 of 2022 Federal 1040:*

	Value
1a. Total amount from Form(s) W-2, box 1
1b. Household employee wages not reported on Form(s) W-2
1c. Tip income not reported on line 1a
2a. Tax-exempt interest
2b. Taxable interest
3b. Ordinary dividends
4a. IRA distributions - if blank, enter 4b value
5a. Pensions and annuities - if blank or rollover, enter 5b value
6a. Social security benefits - if blank, enter 6b value
7. Capital gain or (loss) - if negative, enter "0"
8. Other income from Schedule 1, line 10 - if negative, enter "0"

Fill in the Below Table Based on Page 1 of 2022 Federal 1040:*

	Value
1a. Total amount from Form(s) W-2, box 1
1b. Household employee wages not reported on Form(s) W-2
1c. Tip income not reported on line 1a
2a. Tax-exempt interest
2b. Taxable interest
3b. Ordinary dividends
4a. IRA distributions - if blank, enter 4b value
5a. Pensions and annuities - if blank or rollover, enter 5b value
6a. Social security benefits - if blank, enter 6b value
7. Capital gain or (loss) - if negative, enter "0"
8. Other income from Schedule 1, line 10 - if negative, enter "0"

Fill in the Below Table Based on Page 1 of 2022 Federal 1040:*

	Value
1a. Total amount from Form(s) W-2, box 1
1b. Household employee wages not reported on Form(s) W-2
1c. Tip income not reported on line 1a
2a. Tax-exempt interest
2b. Taxable interest
3b. Ordinary dividends
4a. IRA distributions - if blank, enter 4b value
5a. Pensions and annuities - if blank or rollover, enter 5b value
6a. Social security benefits - if blank, enter 6b value
7. Capital gain or (loss) - if negative, enter "0"
8. Other income from Schedule 1, line 10 - if negative, enter "0"

Fill in the Below Table Based on Page 1 of 2022 Federal 1040:*

	Value
1a. Total amount from Form(s) W-2, box 1
1b. Household employee wages not reported on Form(s) W-2
1c. Tip income not reported on line 1a
2a. Tax-exempt interest
2b. Taxable interest
3b. Ordinary dividends
4a. IRA distributions - if blank, enter 4b value
5a. Pensions and annuities - if blank or rollover, enter 5b value
6a. Social security benefits - if blank, enter 6b value
7. Capital gain or (loss) - if negative, enter "0"
8. Other income from Schedule 1, line 10 - if negative, enter "0"

Total Gross Annual Income

Non-Express Income Calculation*

	Type of Income	Value
Income Type 1
Income Type 2
Income Type 3
Income Type 4
Income Type 5
Income Type 6
Income Type 7
Income Type 8

Total Gross Monthly Income Annualized

AMI %

Household Income Declaration*

I declare my annual household income does not exceed the maximum income limit stated above.My annual household income limit is greater than the amount noted above.

Based on the information provided, you are eligible to receive Income Qualified rebates from Focus on Energy. Complete the remainder of this form and select Submit to finish your Income Qualification Application.

For questions, please call 800.762.7077.

Based on the information provided, you are eligible to receive Income Qualified rebates from Focus on Energy. Complete the remainder of this form and select Submit to finish your Income Qualification Application.

For questions, please call 800.762.7077.

Based on the information provided, you are not eligible to receive Income Qualified rebates from Focus on Energy. Learn more about rebates and incentives for your home by visiting our website or calling us at 800.762.7077.

File Upload*

File Upload

Application Received COMPLETE? (check NO to prevent approval email from sending)

YesNo

Verification

Email Notification

Mail Due Date

Date

ALERT!

You have indicated above that this application is incomplete. Please review this application and update the above field if this application is complete to populate an approval email.

I authorize Focus on Energy to communicate my eligibility status with my Trade Ally contractor.

Trade Ally/Contractor Business Name:

Trade Ally/Contractor Email Address:

example@example.com

Electronic Signature*

Last Updated Date

MonthDayYear

Date Updated

Date

2024 Income Eligibility Application

Household Information

Streamlined Eligibility

Income Eligibility

Application Signature