Low-Income Energy Assistance Rebate Application
Applicant Information
First Name
Last Name
Date of Birth
Phone Number
Email Address
Address
City
Province/State
Postal/Zip Code
Household Information
Number of Household Members
Total Annual Household Income
Energy Details
Utility Provider
Account Number
Service Address (if different)
Supporting Documents
Proof of Income
Recent Utility Bill
Declaration
I certify that the information provided is true and accurate.