Delivering safe and reliable energy to Wisconsin and Upper Michigan

Residential Income Assistance Verification Form

Contact information
Verify and submit
Confirmation

Required field Required

Name is required. Name
Required field

Account number is required.Account number
Required field

Street address is required. Street address
Required field

City/Town is required. City/Town
Required field

State is required. State
Required field

ZIP is required. ZIP A valid ZIP is required.
Required field

Email is required. Contact email A valid email is required.
Phone Required field

List names of adults is required. List names of adults
Is anyone listed on your WPS utility bill 65 or older? Yes

If checked yes, then provide name of the person and their full date of birth:

Name

Date of birth is required. Date of birth:

List monthly income of each adult is required. Monthly income of each adult Required field

Total number of people living in the household is required.Total number of people living in the household (including children)
Does anyone listed on your WPS utility bill receive: Medicaid and/or Supplemental Nutrition Assistance Program (SNAP)? I certify that the above statements are true and correct to the best of my knowledge. I understand that providing a false statement may disqualify me for receiving benefits.

You will need to recertify your income yearly to maintain enrollment in this program.

Emergencies

Natural Gas Leaks

Electric

Residential Income Assistance Verification Form

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