• Power AZ Application Form

  • Account Holder's Date of Birth*
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  • Account Holder Preferred Language*

  • Optional Survey Information

  • What is your sex?

  • You must agree to the following before continuing

    • I understand and agree that this survey serves as an application for utility assistance. I certify, under penalty of perjury, that all information submitted in this survey, and information previously submitted to my utility provider, is true and correct to the best of my knowledge.
    • I understand that DES may investigate and contact any sources necessary to confirm the accuracy of my information when determining my eligibility for this program. I further understand and agree that if I obtain utility assistance based on false information, I will be required to repay all amounts received and may be subject to program disqualification.
    • I understand that I must be a U.S. citizen or qualified noncitizen to be eligible for federal and state public benefits, in accordance with Arizona Revised Statutes § 1-504. I further understand and agree that by submitting this referral survey, I authorize DES to attempt to verify my citizenship or qualified noncitizen status when determining my eligibility for Power AZ.
    • I understand that DES will notify me whether I am approved for this program. If I qualify, I can receive up to $640 that will be paid directly to my utility provider. If I do not qualify based on this referral, I can apply for utility assistance directly with DES at any time at A-to-Z Arizona. If I disagree with DES's determination, I can request a review of the decision.
    • I understand that this survey is for referral purposes only and that completing this survey does not guarantee program eligibility or the disbursement of assistance. I further understand that Power AZ utility assistance is subject to the availability of funding and the receipt of Power AZ benefits in no way guarantees future program availability.
    • I authorize my utility provider (Utility) and DES (“Authorized Parties”) to release and share my information as necessary to process my application for utility assistance. I authorize (Utility) to share my utility account information and the information I have provided in this survey with DES as needed to verify my eligibility and for the distribution of funds (including, but not limited to: account holder's name, service address, account number, household information, usage information, account balance, payment history, historical and future utility bills). I authorize DES to release my application information to (Utility provider) as needed to distribute any benefits I receive.
    • I understand and agree that any utility information released as part of my application may be compiled, analyzed, and released to a third party by DES for reporting purposes that are directly related to any assistance received. No information released under this provision will be made public such that my dwelling or household occupants can be identified. Any information released shall be used solely for the purpose of determining eligibility and administering utility assistance. In no circumstance will information be shared or sold for advertising or marketing purposes.
    • I understand that DES, and not [Utility], provides the funds, and determines the distribution of funds under this assistance program. I agree to release and hold harmless (Utility) from: (i) any claims, damages, liability, or expenses resulting from [Utility]'s good faith use or disclosure of information based on this Authorization; (ii) the unauthorized use or disclosure of the information by any of the Authorized Parties; and (iii) any actions taken by any of the Authorized Parties based on this Authorization.
  • I agree to the above*

  • If you do not agree, your survey will not be reviewed for eligibility. You may still apply for utility assistance directly with DES at any time at A-to-Z Arizona.

  • You may voluntarily provide the personal information required to complete this form. TEP uses this information to fulfill the purpose for which it was obtained. To find out more about the categories of personal information TEP collects and the purposes for which such information will be used, please refer to our Privacy Policy.

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