Residential Income Qualification Form

Applicant Information

*Language Preference

*National Grid Electric Account Number

Please include all zeros and do not include dashes.

*First Name

As it appears on your bill

*Last Name

As it appears on your bill

*Phone Number

*Email Address

*Service Address

Mailing address- if different than service address

*Mailing Address

*Preferred Communication Method

*How did you hear about this offering?

*Number of people living in your household

*Number of Adults

*Number of Children (under 18)

*Total Gross Annual Household Income

This is a National Grid program that CLEAResult is contracted to manage on National Grid's behalf.

I certify that all of the information provided on this application is true, the National Grid residential account above is in my name, and I am income eligible.

I acknowledge that I may be asked to verify proof of eligibility during the two-year program period and that program terms and conditions are subject to change.