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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:

  1. My recent three-month income as reported to my county of residence for fuel energy assistance.
  2. 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.

Name of spouse or significant other is needed if both names are listed on the application for energy assistance with the county.
After completing the CAPTCHA security code below and clicking "Submit," an email will be sent to the email address listed on this form. If you do not receive a confirmation email, please double-check your Junk/SPAM folder and either resubmit your request or feel free to contact the office at 715-796-7000, Monday through Friday, 7:30 a.m. to 4:30 p.m. Thank you.
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