Weatherization Request Form

2013 Percentages of Federal Poverty Guidelines
Family Size 200%
1 $22,980
2 $31,020
3 $39,060
4 $47,100
5 $55,140
6 $63,180
7 $71,220
8 $79,260
Each additional member add $7,920

 

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 received 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 completing the request form for a Weatherization Application Packet. Click the Submit Form button below to submit your form. An application packet will be mailed to you within the next 2 weeks.

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