EES (rev 2026

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The document is a Utilities Verification Statement Form from the Energy and Environmental Services Department, designed for landlords and property managers to provide information regarding utility costs included in rent for tenants applying for assistance under the Low-Income Home Energy Assistance Program. It requires details about the tenant's living situation, rent payments, and types of fuel included in the rent, along with certifications from either the landlord or tenant.

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Click ‘Get Form’ to open the EES (rev) in the editor.
Begin by filling out Section I with your first name, middle initial, last name, service address, unit number, city, state, and zip code.
In Section II, answer the questions regarding the tenant's residency and any rental subsidies. Be sure to provide the monthly rent amount paid by the tenant.
Check all applicable fuel types included in the rent and indicate the monthly amounts for each type of fuel listed.
Proceed to Section III where either you or your landlord must complete the certification. If self-certifying as a tenant, provide a brief hardship statement detailing why you cannot obtain landlord certification.
Finally, ensure all signatures are completed along with dates before submitting the form.

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EES (rev 2026

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