Weatherization Form

This form is designed to help you apply quickly for Weatherization services.

Please review the guidelines before you continue:

EFFECTIVE JAN 25, 2008 — PERCENTAGES OF FEDERAL POVERTY GUIDELINES
Family Size 150%
1 $15,600
2 $21,000
3 $26,400
4 $31,800
5 $37,200
6 $42,600
7 $48,000
8 $53,400
Each Additional $5,400

Weatherization Form

Please Fill out form completely. If additional information is needed regarding an answer, new fields will be displayed.
Name:
Phone Number:
Address:
City:
State:
Zip Code:
County:
E-mail:
How many years have you lived at this residence?
Is your house/trailer up for sale or are you planning to move?
Have you recieved weatherization before?
How many people reside in your home?
How many residents are over 60?
How many are handicapped/disabled?
How many have received income in the last 12 months?
Approximate income for all members of the household for the past 12 months:
Sources of income for the past 12 months:




Fuel Assistance?
Housing Type:
Primary Heating Fuel:
Secondary Heating Fuel:
Do you use unvented heaters?
Who is your electric company?
What kind of water heater do you use?
Yearly cost of heating:
Yearly cost of electricity:
Paying Rent?
Buying?
Landlord?
Names on Deed:
Own?
Life-Use?
Rent-Free?
Land Contract?
Thank you for filling out our weatherization application form. Click the Submit button below to submit your form. You will be contacted shortly regarding your application.