Winter Termination Program Self-Certification Form

As an alternative to verbally advising their utility company of their eligibility to receive protection under the Winter Termination Program, customers may complete this Self-Certification form and submit the form to their utility company or companies. It is recommended that a copy of this form be retained by the customer for their records.

Please note that completion and submission of the Self-Certification form to your utility company is NOT required in order to receive protection under the Winter Termination Program. Protection under the Winter Termination Program can be obtained by verbally advising your utility company or companies of your eligibility or by submitting this Self-Certification form to the utility company.

Upon submitting this form, you will receive a copy via email, and your utility company will be notified.

Household Information

Please enter the head of household's information, as well as the street address of your home below.

First Name

Last Name

Household Address

Email Address

Phone Number

Utility Information

In this section, please tell us about the utility companies that provide service to your home. If you receive an electric bill from one provider and gas from another, please provide both accounts below.

How many utility companies are you a customer of?

1

2

Company 1 Value is not selected

Utility Account Number for Company 1

Company 2 Value is not selected

Utility Account Number for Company 2

WARNING:

You have listed a utility company that requires further action. There is a list of requirements you must complete to ensure you are fully protected. Please check your email for more information.

Qualification

In this section, you will answer questions about your qualifying circumstances, and how you may qualify for participation in the Winter Termination Program.

Do you currently receive public assistance? If your household participates in programs such as TANF, HEAP or SSI you receive assistance and could qualify for Winter Termination Program protection.

Yes

No

Are you unable to pay your utility bill due to circumstances beyond your control? If you were laid off, had an illness or suffered a financial hardship you could qualify for Winter Termination Program protection.

Yes

No

We're sorry, but based upon your responses, it appears that you are not eligible.

Please visit the Department of Community Affairs website for more information about the Winter Termination Program and eligibility requirements.

Based on your prior answers, please tell us about the public assistance programs your household participates in.

Your personal information will be kept confidential.

I certify that I am receiving assistance from one or more of the below programs and am requesting protection under the NJ Department of Community Affairs’ Winter Termination Program:

Federal Home Energy Assistance Program (HEAP)

Temporary Assistance to Needy Families (TANF)

Federal Supplemental Security Income (SSI)

Pharmaceutical Assistance to the Aged and Disabled (PAAD)

General Assistance (GA) benefits

Universal Service Fund (USF)

Lifeline Credit Program

Are there any other details you would like to provide? (optional)

Based on your prior answers, please tell us about the circumstances regarding your inability to pay.

Your personal information will be kept confidential.

I certify that I am unable to pay my local authority and/or municipal utility bill due to circumstances beyond my control and am requesting protection under the NJ Department of Community Affairs’ Winter Termination Program. Please select the circumstances under which you are requesting protection under the Program:

Laid off/unemployed

Illness

Medically related expenses

Recent death of an immediate family member

I am a SNAP recipient who was affected by federal funding lapses

Is there anything else that you would like to share?

Certification

Please sign and check the box to confirm the accuracy of your information.

I understand that completing this form does NOT give me Winter Termination Program protection. I must call my utility to complete the process. *

I certify the foregoing statements made by me are true. I understand that if any of the foregoing statements made by me are willfully false, I am subject to punishment in accordance with law. *

Signature

Date

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