Medical Assistance Program Renewal

The Medical Assistance Program (MAP) provides a discounted electric rate for medically necessary equipment or air conditioning.

This form must be completed by the Fort Collins Utilities account holder.
Information provided will not be shared or used for any other purpose.
If your medical condition has changed, please visit fcgov.com/MAP to reapply with the original program application.

1. Utility Account Holder Name *This question is required.

2. Fort Collins Utilities Account Number *This question is required. Account number can be found on your utility bill or by calling 970-212-2900.
Include dash (XXXXXX-XXXXX)

3. Service Address: *This question is required.

Street Address (include Apt/Suite if applicable)

City

State

Zip

4. Best Phone Number *This question is required. Include dashes (XXX-XXX-XXXX)

5. Best Email (not required but highly encouraged) This question requires a valid email address.

6. Name of resident requiring assistance: *This question is required.

7. Number of people in household: *This question is required.

8. Annual household income range: *This question is required.

9. Please select an option below: *This question is required.

60% Larimer County Area Median Income
Find the income limit associated with the number of people in your household.

1 person: $45,120
2 people: $51,540
3 people: $57,960
4 people: $64,380
5 people: $69,540
6 people: $74,700
7 people: $79,860
8 people: $85,020

Affidavit of income eligibility
This program is intended to assist customers for whom the costs of running a medical device results in an economic hardship. The income threshold for this program has been set at 60 percent of the Larimer County Area Median Income (as determined by the Federal Housing Authority). Based on the number of people within this residence and the income ceiling provided in the table above, I certify that the total household income is less than the income ceiling and, thus, this account is eligible for this program. I agree, as a condition of my participation in this program that if asked, I will provide copies of my financial records establishing my household income, including copies of my IRS tax returns.

My signature below certifies all information on this application is true and accurate that the total household income for this residence is less than the household size-adjusted income ceiling in the table above, and the resident named above lives at this address full time and requires medically necessary equipment, used at this address, which requires electricity to operate. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal law of Colorado as perjury in the second degree under C.R.S. 18-8-503, and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.

10. Consent to Contact *This question is required.

I consent for Utilities to contact me by email, telephone or mail regarding participation in MAP.

11. Account holders's signature *This question is required.

Clear

Signature of

12. Date *This question is required. This question requires a valid date format of MM/DD/YYYY.

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