Permission for WIC to Give EVERSOURCE My Application for the EVERSOURCE Discount Fuel Program

and to Verify My Income

I am aware that by law WIC officials cannot give information about me to EVERSOURCE without my written permission. By signing this permission form, I voluntarily give WIC staff my permission: (1) to release information on this application to EVERSOURCE so that I can get a discount on my monthly EVERSOURCE electric and/or gas bill and (2) to verify that my income meets EVERSOURCE income guidelines. I understand that:

  • WIC staff will not give any other information about me to EVERSOURCE.
  • EVERSOURCE will use this information only for the fuel discount program and will not use or disclose this information for any other purpose.
  • I am entitled to get WIC checks and services even if I do not sign this permission form or the EVERSOURCE application.
  • the EVERSOURCE discount will not affect any WIC benefits or other government benefits I may receive.

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EVERSOURCE Discount Fuel Program Application

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Last Name of Participant (Please Print) First MI
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Last Name of Account Holder (Please Print) FirstMI

(if different from above)

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Address CityZip
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Telephone Number Signature Date signed

EVERSOURCE Electric Account Number: ______

EVERSOURCE Gas Account Number: ______

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Verification Form for Automatic Eligibility for EVERSOURCE Discount Fuel Program

The WIC Program verifies that this family meets the income guidelines for the EVERSOURCE discount fuel rate:

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Name of Authorized WIC Representative TitleDate

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Name of local WIC Program

Completed form should be faxed to 781-441-8512 OR mailed to: EVERSOURCE, Attention: Discount Rate Team, One EVERSOURCE Way, Westwood, MA 02090

In an effort to process the application efficiently, the EVERSOURCE account for electricity or gas must be in a household member’s name. In addition, if the EVERSOURCE account is not in the participants’ name, EVERSOURCE is requesting that both household names be placed on the application for the discount fuel program. Please provide program staff with this information to ensure that the application is completed during income screening.

Please remember that EVERSOURCE prefers that WIC staff fax the completp

ed applications to Discount Rate Team at 781-441-8512. If programs do not have access to a fax machine, the applications should be mailed to the main site so they can be faxed from the program to EVERSOURCE. Forms should NOT be given to participants to mail themselves. The discounted rate code R-2 will appear on the bill, generally within one billing cycle

EVERSOURCE Service Area FOR Quincy Office

Canton, Dover, Medfield, Milton, Norfolk, Scituate, Sharon, Walpole, Westwood