New Jersey Comfort Partners Program

Customer Information

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone (Primary) *

Phone (Secondary)

What is the best time to call?

List name of spouse or other individual we can speak with

Eligibility Information

Gross monthly income (all household residents ages 18+)

Number of persons (residing in the household)

Check if you participate in:

Type of Heating Fuel: *

Natural Gas
Electricity
Oil
Other Fuel

Name of Electric Company: *

Electric Account Number:

Name of Gas Company: (if applicable) *

Gas Account Number:

Type of dwelling: *

1 - 14 Unit Dwelling
15+ Dwelling (not eligible)

Own
Rent (Landlord consent will be necessary)

Do you pay directly for your heating? *

Yes
No

Type of Account: *

Residential
Commercial (not eligible)

Do you own your refrigerator? *

Yes
No

Is your utility service currently active? *

Yes
No (Site visit cannot be scheduled until activated)

Authorized Signature

I certify that all information provided above is correct to the best of my knowledge, and I give participating New Jersey Comfort Partners utilities and contractors permission to: 1) share my records with all parties planning to do work on my home or evaluate my energy usage; 2) use, at no charge, any description or pictures relating to the work performed at my home; and 3) have reasonable access to my home to inspect the work performed. I understand that all work is guaranteed for a period of one year.

Customer Signature *

Date *