Public Benefits Information Release Form
Please complete and submit.
I hereby authorize the Department of Human Services to release to St. Croix County Electric Cooperative – my electric energy supplier – the following information:
- My recent three-month income as reported to my county of residence for fuel energy assistance.
- The number of dependants reported to my county of residence for fuel energy assistance.
I understand this information is necessary in order for St. Croix Electric Cooperative to consider me/my household for the Public Benefits Electric Energy Assistance Program.