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Home Energy Assessment (Akwesasne Housing Authority)

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Home Energy Assessment
APPLICATION
Most New York homeowners can receive a home energy assessment for free or at a reduced-cost through the
Home Performance/Assisted Home Performance with ENERGY STAR
®
program. The assessments are available
on a first come, first served basis. Save time and apply online at nyserda.ny.gov/apply-online
To qualify, you need to meet these requirements:
1. You must be the owner, or be authorized to sign for the owner, of a 1- to 4-unit residential building.*
2. Your total household income must meet the guidelines on page 2.
3. You must not have previously received a free or reduced-cost assessment on the building listed below.
APPLICANT/HOMEOWNER INFORMATION (Please complete all fields, sign and date this application)
First Name Middle Initial Last Name
Building Address City
oun
Mailing Address (if different than the above) City
C ty
State
ZIP
NY
State ZIP
Home Phone Cell Phone Email Address
( ) ( )
Residential Building T
ype (5+ units do not qualify)*
Single Family
2-Unit
3-Unit
Do you have Central Air Conditioning?
4-Unit
Yes
No
HOUSEHOLD INCOME RANGE
Is your household income less than $99,600?
Yes
If no, then please refer to attached chart and indicate your annual household income range below.
≤ 200% AMI**
≤ 250% AMI
≤ 300% AMI
≤ 350% AMI
≤ 400% AMI
HOW DID YOU HEAR ABOUT HOME PERFORMANCE WITH ENERGY STAR? (Optional)
Please select all that apply:
Print Ad
TV
Radio
Internet
Event/Home Show
Neighbor/Friend/Family
Contractor
EDGE Regional Outreach Contractor
Real Estate Professional
Town, Village, City, County
NYSERDA
Constituency-Based Organization (CBO) Name:
ELIGIBILITY DECLARATION
By signing below, I certify that the information listed on this form is true and accurate to the best of my knowledge and belief. I understand that my
signature on this form gives permission for NYSERDA, or its designee, to verify my eligibility for a free or reduced-cost assessment. I understand that
false or withheld information may result in penalties.
X
Applicant/Homeowner’s Signature Date
When complete, please mail, fax, or email the signed application to:
*Condo, co-op, not-for-profit, or mobile home owners please call
(855) 838-7818 to see if you are eligible.
Mail: Home Energy Assessments Fax: (866) 335-6306
PO Box 12129 Email: HPwES-Audit@csgrp.com
**Area Median Income (AMI) represents the statistical midpoint in
household earnings for each county.
Albany, NY 12212
Need Help? Call (855) 838-7818
Please send a copy of my home energy assessment Reservation Number to the Home Performance
Contractor that I have chosen below. NYSERDA does not assign contractors.
Contractor Name
Page 1 of 2 HP-web
✔
ANCA – Adirondack North Country Association (North Country Region)
DETERMINE YOUR HOUSEHOLD INCOME RANGE
If your household income is greater than $99,600,
use the chart below to find where it falls in relation
to your county’s median income. This will determine
the cost, to you, of your home energy assessment (if any).
1. Find your county (this is where the home you wish
to have assessed is located).
2. Use the corresponding columns to find the range
that includes your household income.
3. Check the appropriate box on the front of the application.
HOME ASSESSMENT FEE SCHEDULE
Use your household income range from the chart below
and the chart to the right to determine the cost, to you, of
your assessment (if any).
HOME ENERGY ASSESSMENT FEE SCHEDULE
Household
Income
Range
Single-Family Homes
Less than 3,500 Square Feet*
Cost to NYSERDA Payment
Customer to Contractor
2-4 Unit Residential Building or
Single Family Homes ≥ 3,500 Square Feet*
Cost to NYSERDA Payment
Customer to Contractor
≤ 200% AMI - 0 - $250 - 0 - $400
>200-250% AMI $50 $200 $80 $320
>250-300% AMI $100 $150 $160 $240
>300-350% AMI $150 $100 $240 $160
>350-400% AMI $200 $50 $320 $80
> 400% AMI Market Rate - 0 - Market Rate - 0 -
*Above grade conditioned space.
HOUSEHOLD INCOME GUIDELINES–2014
RES-HP-assessment-app-1-v2 9/14
Page 2 of 2
County Name
Median House-
hold Income
≤ 200% ≤ 250% ≤ 300% ≤ 350% ≤ 400%
Albany $78,300 $156,600 $195,750 $234,900 $274,050 $313,200
Allegany $52,600 $105,200 $131,500 $157,800 $184,100 $210,400
Broome $62,900 $125,800 $157,250 $188,700 $220,150 $251,600
Cattaraugus $49,800 $99,600 $124,500 $149,400 $174,300 $199,200
Cayuga $62,600 $125,200 $156,500 $187,800 $219,100 $250,400
Chautauqua $50,900 $101,800 $127,250 $152,700 $178,150 $203,600
Chemung $63,400 $126,800 $158,500 $190,200 $221,900 $253,600
Chenango $56,200 $112,400 $140,500 $168,600 $196,700 $224,800
Clinton $66,000 $132,000 $165,000 $198,000 $231,000 $264,000
Columbia $74,000 $148,000 $185,000 $222,000 $259,000 $296,000
Cortland $60,100 $120,200 $150,250 $180,300 $210,350 $240,400
Delaware $57,500 $115,000 $143,750 $172,500 $201,250 $230,000
Dutchess $83,100 $166,200 $207,750 $249,300 $290,850 $332,400
Erie $63,900 $127,800 $159,750 $191,700 $223,650 $255,600
Essex $59,500 $119,000 $148,750 $178,500 $208,250 $238,000
Franklin $54,600 $109,200 $136,500 $163,800 $191,100 $218,400
Fulton $55,500 $111,000 $138,750 $166,500 $194,250 $222,000
Genesee $65,300 $130,600 $163,250 $195,900 $228,550 $261,200
Greene $58,400 $116,800 $146,000 $175,200 $204,400 $233,600
Hamilton $64,100 $128,200 $160,250 $192,300 $224,350 $256,400
Herkimer $59,500 $119,000 $148,750 $178,500 $208,250 $238,000
Jefferson $54,000 $108,000 $135,000 $162,000 $189,000 $216,000
Lewis $55,900 $111,800 $139,750 $167,700 $195,650 $223,600
Livingston $67,000 $134,000 $167,500 $201,000 $234,500 $268,000
Long Island: Nassau & Suffolk $105,100 $210,200 $262,750 $315,300 $367,850 $420,400
Madison $67,700 $135,400 $169,250 $203,100 $236,950 $270,800
Monroe $67,000 $134,000 $167,500 $201,000 $234,500 $268,000
Montgomery $57,000 $114,000 $142,500 $171,000 $199,500 $228,000
New York City: Bronx, Kings, New York, Queens, Richmond $62,500 $125,000 $156,250 $187,500 $218,750 $250,000
Niagara $63,900 $127,800 $159,750 $191,700 $223,650 $255,600
Oneida $59,500 $119,000 $148,750 $178,500 $208,250 $238,000
Onondaga $67,700 $135,400 $169,250 $203,100 $236,950 $270,800
Ontario $67,000 $134,000 $167,500 $201,000 $234,500 $268,000
Orange $83,100 $166,200 $207,750 $249,300 $290,850 $332,400
Orleans $67,000 $134,000 $167,500 $201,000 $234,500 $268,000
Oswego $67,700 $135,400 $169,250 $203,100 $236,950 $270,800
Otsego $60,600 $121,200 $151,500 $181,800 $212,100 $242,400
Putnam $62,500 $125,000 $156,250 $187,500 $218,750 $250,000
Rensselaer $78,300 $156,600 $195,750 $234,900 $274,050 $313,200
Rockland $100,200 $200,400 $250,500 $300,600 $350,700 $400,800
Saratoga $78,300 $156,600 $195,750 $234,900 $274,050 $313,200
Schenectady $78,300 $156,600 $195,750 $234,900 $274,050 $313,200
Schoharie $78,300 $156,600 $195,750 $234,900 $274,050 $313,200
Schuyler $57,300 $114,600 $143,250 $171,900 $200,550 $229,200
Seneca $57,700 $115,400 $144,250 $173,100 $201,950 $230,800
St. Lawrence $54,000 $108,000 $135,000 $162,000 $189,000 $216,000
Steuben $54,500 $109,000 $136,250 $163,500 $190,750 $218,000
Sullivan $63,200 $126,400 $158,000 $189,600 $221,200 $252,800
Tioga $62,900 $125,800 $157,250 $188,700 $220,150 $251,600
Tompkins $78,800 $157,600 $197,000 $236,400 $275,800 $315,200
Ulster $71,300 $142,600 $178,250 $213,900 $249,550 $285,200
Warren $62,900 $125,800 $157,250 $188,700 $220,150 $251,600
Washington $62,900 $125,800 $157,250 $188,700 $220,150 $251,600
Wayne $67,000 $134,000 $167,500 $201,000 $234,500 $268,000
Westchester $103,700 $207,400 $259,250 $311,100 $362,950 $414,800
Wyoming $62,600 $125,200 $156,500 $187,800 $219,100 $250,400
Yates $60,900 $121,800 $152,250 $182,700 $213,150 $243,600
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Home Energy Assessment (Akwesasne Housing Authority)

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Completed 11 November 2021

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