Energy Efficiency Kit Order Acknowledgment Form

Home Efficiency Income Qualified Initiative Customer Application

It only takes about 3 minutes to complete this important step towards saving energy and money.

By submitting this application, you are applying to receive a Home Energy Assessment through the Ameren Illinois Energy Efficiency Program. Following your submission, a Program representative will contact you with more details.

If you have any questions, please call us at 1.866.838.6918.

Please verify that you meet the basic eligibility requirements of the Program:

Live in a single family home (A single family home is a free-standing residential building. Single family homes are designed to be used as a single-dwelling house.) *

Is this a Mobile Home? Mobile Homes do not qualify for this Initiative. Visit AmerenIllinoisSavings.com/MobileHome to learn about opportunities for you.

Is this a Duplex?

Must be an Ameren Illinois residential customer heating your home with gas or electricity delivered by Ameren Illinois.
OR Must be an Ameren Illinois residential electric customer heating your home with propane.

Maximum Gross Annual Household Income is at or below the amount listed on the Income Qualifications Chart at AmerenIllinoisSavings.com/Qualify? *

If you are living in an apartment or townhouse, please follow the link and nominate your building for a FREE Energy Assessment AmerenIllinoisSavings.com/NominateYour Building.

If you own or rent a house, please complete the following application:

Account Number (If you are unable to locate or access your Ameren Illinois account number, please reach out to our customer care center for assistance: 1.800.755.5000) *

Format: ########## (no dashes)

Account Holder First Name *

Account Holder Last Name *

Address *

City *

Zip Code *

Customer Email Address (If you do not have an email address, please call us at 1.866.838.6918). *

Cell Phone *

Format: 000-000-0000

Home Phone

Format: 000-000-0000

How did you hear about us/Were you referred by? *

If other, please explain

If you were referred by a Community Action Agency or Community Organization, please select from the options below *

If you were referred by a Program Ally, please select from the options below (Program Allies are contractors enrolled in our Program) *

Do you own your home? *

Yes

Primary Heat Source *

Gas

Electric

Propane

Type of foundation in your home, Check all that apply *

Basement

Crawl Space

Slab

Are you able to provide proof of participation in any of the following income based assistance programs? (proof of participation may eliminate the need for additional income documentation.) Check all that apply

Number of Members in Home, including yourself *

Number of Adults *

Number of Children *

List Full Names of Adults living in the home full time (include the Account Holder)

List First Names of Children living in the home full time *

Currently live in your home, check all that apply *

By checking this box, I confirm that all information listed above is true and accurate and completing this application does not guarantee my household will receive incentives. Ameren Illinois may change the Program requirements, incentives, or terms and conditions at any time. The Program can send your contact information to Program Allies related to your project. *

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