APPLICATION REQUEST FORM

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This program requires that the home be located within Yamhill County. This form must be completed in full to be placed on the application request list for Energy Assistance. Applications are mailed out on a first requested first served basis. Turnaround time between application request and application mailing may vary upon funding availability and staff capacity.

Oct 1st through November 30th: Priority to senior and/or disabled households
Dec 1st to September 30th: Wait list opens to general population.

* This is not an application*

Please only complete this form one time per household unless a change is needed due to error.

LIHEAP: (Low-Income Home Energy Assistance Program)

OEAP: (Oregon Energy Assistance Program) for PGE customers only

OLGA & GAP: (Oregon Low-Income Gas Assistance & Gas Assistance Program) for NW Natural Gas customers only

Email *

First and Last Name *

Mailing Address *

City / State / Zip *

Contact Phone Number *

Please list your electric, gas or bulk fuel utility. *

Number of people in the Household *

Is anyone in the home senior or disabled? *

Any children under 6 years old in the household? *

Is there a heating system failure causing you to have No Heat? *

Energy Education Workshops

Would you like to learn how to save up to 20% on your energy bills? YCAP's Energy Education Workshops to the rescue! We will discuss valuable tips and techniques to save you money and give you some energy saving "goodies" to take home.

Interested in attending an "Energy Education Workshop"

Has the home been weatherized?

Where you referred to us? If so, by Who?

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms