Form 18 - Energy Conservation Improvement Fund Program Application
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1Energy Conservation Improvement
FORM
18
Fund Program Application
PLEASE DO NOT WRITE IN ThIS SPACE
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Nebraska Identification Number
Federal Employer I.D.
NAME AND LOCATION ADDRESS
NAME AND MAILING ADDRESS
Name Doing Business As
Name
Legal Name
Street Address
Street or Other Mailing Address
City
State
Zip Code
City
State
Zip Code
1 Check the box which applies to the applicant:
Public power district organized under Neb. Rev. Stat. §§ 70-601 through 70-681;
(1)
Rural public power district organized under Neb. Rev. Stat. §§ 70-801 through 70-809;
(2)
Electric cooperative corporation organized under the Electric Cooperative Corporation Act;
(3)
Nonprofit corporation organized for the purpose of furnishing electric service;
(4)
Joint entity organized under the Interlocal Cooperation Act; or
(5)
Municipality.
(6)
2 Who is to administer the Low-Income Home Energy Conservation grant program for your organization?
Applicant
A qualified person, agency, or business entity other than the applicant. Identify below:
Name of Qualified Person, Agency or Entity
Street Address
E-Mail Address
Telephone Number
3 Attach documentation from your governing body indicating commitment to this program, such as a resolution, meeting
minutes, or budget document(s).
4 Person to contact regarding this application:
Name
Title
E-Mail Address
Daytime Telephone
Under penalties of law, I declare that I have examined this application, and to the best of my knowledge and belief, it is correct and complete.
sign
here
Signature of Owner(s), Corporate Officer, or Other Authorized Person
Date
Telephone Number
Title
INSTRUCTIONS
WhO MAY FILE. Only the types of entities listed on line 1 of this application.
PURPOSE OF APPLICATION. This application allows the Department to verify entity qualifications and to begin creation
of a subaccount for funds your entity will remit for low-income home energy conservation, matching state funds, and grant
distribution purposes.
DIRECT DEPOSIT OF DISTRIBUTIONS. To have your future grant distributions deposited directly into your checking
or savings account, it is necessary to be actively enrolled in the State Treasurer’s Automated Clearing House (ACH) program.
If you wish to enroll, the
State Treasurer’s ACH form
is available at
Mail this application to: NEBRASKA DEPARTMENT OF REVENUE, P.O. BOX 94818, LINCOLN, NE 68509-4818
, (800) 742-7474 (toll free in NE and IA), (402) 471-5729
6-488-2009 Rev. 6-2009
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