Please read this form carefully.
"*" indicates required fields
By completing this form, you are giving the Maine Department of Health and Human Services (DHHS) Office for Family Independence (OFI) permission to share certain information with Efficiency Maine.
What is the purpose of the disclosure?
To see if my/my household income level qualifies for Efficiency Maine’s Low-Income Initiatives that could bring down my energy costs.
What information will OFI share with Efficiency Maine?
If you are a Personal Representative (parent, guardian) please enter the name and information of the person who receives/received DHHS benefits.
First* Middle Initial Last* (Jr, III, etc.)