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Weatherization Pre-Application

  1. Has you or any member of your household received: (Check Boxes)

  2. Household Members (voluntary) # of people in household who are:

  3. ADDRESS INFORMATION

  4. Lived at Residence:

  5. Housing Status:

  6. Housing Type:

  7. Primary Heat Source:

  8. Income / Benefits:

  9. Estimated total household income for past 3 months

  10. COMPLETE FOR ALL HOUSEHOLD MEMBERS

  11. Has the home been previously weatherized?

  12. Roof Type

  13. Roof Leaks

  14. Walls

  15. Rot?

  16. Holes?

  17. Finished?

  18. Floors

  19. Holes?

  20. Soft Spots?

  21. Windows

  22. Any Broken Windows?

  23. Do you get condensation on windows?

  24. Mold?

  25. Other

  26. Dryer Vented

  27. Any Plumbing Leaks?

  28. Any Exhaust Fans?

  29. After you click Submit, please allow a few seconds for your request to process, at which time you will be redirected to a confirmation page. Do not click Submit again.

  30. Leave This Blank:

  31. This field is not part of the form submission.