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Income Eligibility Application

To qualify for NYSERDA programs that offer incentives based on income eligibility, you must complete this form and upload relevant documentation in the “Supporting Documentation” section. You can demonstrate income eligibility through two options:

Option 1 (upload in the “Supporting Documentation” Section): 

Upload your entire award letter dated within the past 12 months for one of the following:

  • EmPower New York
  • HEAP (Home Energy Assistance Program)
  • SNAP (Food Stamps)
  • TANF (Temporary Assistance for Needy Families)
  • Supplemental Security Income

Option 2 (upload in the “Supporting Documentation” Section): 

If you cannot provide the documents in option 1, please provide the following income documentation as it applies:

  • Social Security and/or Social Security Disability (copy of award letter(s))
  • Documentation of all forms of income including:
    • Disability
    • Worker’s compensation
    • Unemployment
    • Pension
    • Maintenance
    • Child support
    • Annuities
    • Veteran’s benefits
    • Tax Returns (This option is only available if all household members who were required to file a tax return did so. If documenting income with tax returns, all sources of income must be documented with tax returns. Returns must be the most recent Federal Income Tax Return (Form 1040, 1040A, or 1040EZ or W-2))
    • All other income (i.e. paystubs for all household gross income for the last 60 days.)
      • Weekly: multiply weekly income representing 4 most recent weeks by 4.3
      • Bi-weekly: multiply 2 most recent consecutive weeks by 2.15
      • Twice a month: multiply by 2
    • Self-Employment IRS Report of Quarterly earnings for the past three months

STOP: If you are applying to the EmPower New York or Assisted Home Performance with ENERGY STAR® program DO NOT apply using this application. Instead, please apply directly to the programs via the Combined Residential Application.

Please note: Partially completed information cannot be saved, be sure to have all details with you before beginning the form. For the best form completion experience, use the Google Chrome browser. Upon submission, you will receive a confirmation and a tracking number on your screen to print or save. Refer to this tracking number to check on the status of your request.

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Applicant Information

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Household Information

Program Offerings

Are you interested in one or more of these program offerings?

Solar electric installation through the Affordable Solar Program. To learn more visit https://www.nyserda.ny.gov/All-Programs/NY-Sun/Solar-for-Your-Home/Paying-for-Solar/Incentives-and-Financing

Energy Efficiency Upgrades: Incentives for various measure to make your home more energy efficient. Please apply directly to the program: https://www.nyserda.ny.gov/ny/ahp-empower 

Community Solar Subscriptions through the Inclusive Community Solar Adder Program. To learn more visit: https://www.nyserda.ny.gov/All-Programs/NY-Sun/Solar-for-Your-Home/Community-Solar/Community-Solar-Map 

Income Screening

Are you currently eligible for, or have received within the past 12 months, services through NYSERDAs EmPower NY Program, NYS Weatherization Assistance Program, HEAP, SNAP(Food stamps), or Supplemental Security Income? If your household receives any of these services or sources of income, please provide copies of your award letters in the Supporting Documentation attachment Section.

Household Information

Supporting Documentation

Please upload your entire award letter dated within the past 12 months for one of the following:

  • EmPower New York
  • HEAP (Home Energy Assistance Program)
  • SNAP (Food Stamps)
  • TANF (Temporary Assistance for Needy Families)
  • Supplemental Security Income

Award Letter

Click Here to Upload

Please provide the following income documentation as it applies

  • Social Security and Social Security Disability: copy of award letter
  • Documentation of all forms of income including:
  • Disability
  • Worker’s compensation
  • Unemployment
  • Pension
  • Maintenance
  • Child support
  • Annuities
  • Veteran’s benefits
  • Tax Returns (This option is only available if all household members who were required to file a tax return did so. If documenting income with tax returns, all sources of income must be documented with tax returns. Returns must be the most recent Federal Income Tax Return (Form 1040, 1040A, or 1040EZ or W-2))
  • All other income (i.e. paystubs for all household gross income for the last 60 days.)
    • Weekly: multiply weekly income representing 4 most recent weeks by 4.3
    • Bi-weekly: multiply 2 most recent consecutive weeks by 2.15
    • Twice a month: multiply by 2
  • Self-Employment IRS Report of Quarterly earnings for the past three months

Please ensure your document file name does not include any special characters, such as ~! @#$%^&*_-+=`|\(){}[]:;"'<>,.?/. 

Income Documentation

Click Here to Upload

Other Relevant Documents

Click Here to Upload

Contractor Information

If you are working with a Contractor and would like them to be kept apprised of the status of this application please complete this section below.

Attestation

By signing below, I certify that all information provided on this application, including statements and documents submitted in connection with this application, are correct and complete to the best of my knowledge. I acknowledge that NYSERDA has retained a Contractor to process my income qualification application. If necessary, I further agree to provide additional information to complete my income screening application process.

I further acknowledge and agree that NYSERDA and its Contractor may share with and disclose to, orally and/or in writing the project partners identified by me above, or as subsequently identified by me to the Contractor, the following information regarding this application; whether the application has been approved by the Contractor, and any additional items requested by the Contractor in order to complete my income qualification application; whether the application has been approved by the Contractor; and whether my application has been denied, so that the project partner(s) can determine whether I intend to proceed.

I understand that my signature on this form gives permission for NYSERDA, or its designee, to verify records necessary to assure my program eligibility. I understand that if I give false information or withhold information in order to make myself eligible for benefits that I am not entitled to, I can be prosecuted to the fullest extent of the law.

I understand this application does not guarantee assistance will be granted but will be used in determining eligibility for the program. Whether or not an eligible applicant will be provided assistance will depend in part upon the number of applicants received, the remaining funding available, and the priorities to be met by the program.

Whether or not the undersigned have elected to sign this document electronically, the Contractor, and or any subsequent holders of this document, shall have the right to convert and store the manual signature electronically, and the undersigned consents to the use of electronically stored version in the same manner as an original signed copy.

I understand and intent that a legal signature is formed by entering my name on this and other documents provided to me, and by entering my name on this and other documents provided in relation to this transaction I intent for my electronic signature to have the same force and effect as my manual signature. If any of the parties do not wish to sign this document electronically all must opt out together and request a paper copy to sign manually.

Authorized Signature

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Tracking Number

You will be provided with a Tracking Number upon submission.