Fillable Weatherization Application Checklist (Utah Community Action)

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Weatherization Application Checklist (Utah Community Action)

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Rev: 12/2017
Applicant Name: _____________________ Date:________ Job #:_____ (OFFICE USE ONLY)
Weatherization Application Checklist
PLEASE MARK ITEMS INCLUDED WITH APPLICATION- INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED
Weatherization Application:
Completed & Signed (A1-A2)
Utilities:
Utility Bill History Release Authorization (A3) and
Copy of Most Recent Utility Bills- Gas and Electric
Health and Safety:
Health and Safety Evaluation (A4) and
ASHRAE Approval (A5)
Home Ownership (Provide Applicable Option)
Property Tax Notice or Recorded Deed or
Mobile Home Title (Must be in Applicant’s Name) or
Income Property Owner Weatherization Agreement (Renters Only)
HEAT Eligibility:
HEAT Approval (Approval Date:________________ )
Without HEAT Approval:
Copy of the Social Security Card for each member of the household.
Proof of Income
3 months of income (include pay statement) for all those 18 years of age and
older residing in the household and/or
Current yearly benefit/award letter from the Social Security Office and/or
Household Income Deficit Statement for anyone 18 years and older without
income.
Proof of Age – All birthdates must be provided and legible on application
Proof of Disability (If Applicable)
Questions/Concerns:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
To Submit Your Application or Contact Us with Questions:
Weatherization
850 West 1700 South Suite 1
Salt Lake City, UT 84104
Phone: 801-214-3215
Fax: 801-214-3208
Email: weatherization@utahca.org
Updated: 06/2017
*Head of household:
First Middle Last
Address: City, St. Zip:
Phone#: Secondary #: Email:
Family Type (Circle one): Elderly
Single Household Two Parent Household Single Parent Female Single Parent Male
Health Insurance Provider for family members: List household members who do not have Health Insurance:
All household members
Name (Last, First)
Date of
Birth
(mm/dd/yyyy)
Age
Sex
Relationship
to Applicant
Social Security
Number
Veteran
Y N
Disabled
Y N
Income
Y N
U.S.
Citizen
Y N
*Race
(See
Legend)
**Highest
Level of
Education
*Head of household
(Listed above)
Self
List additional family member’s on a separate sheet of paper
*Race: NA = Native American C = Caucasian H = Hispanic AF = African American A = Asian PI = Pacific Islander Other = Explain
**Education: HD = High School Diploma
GED
C = College SS = Still in School Other = Explain
This application is for a home Weatherization grant for low-income households and is funded by the U.S. Department of
Energy, U.S.
Department of Health & Human Services, Rocky Mountain Power and Questar Gas. Proof of income must be
included with your
application (see attached instructions). Income from all sources must be calculated before taxes and
deductions. All household
members must submit a copy of their social security card with this application; unless you have
been approved for the HEAT program.
I hereby give permission to the administering local agency, State of Utah, U.S. Department of Energy, Rocky Mountain
Power, and
Questar Gas to inspect the real property I occupy in order to determine weatherization needs, complete the
weatherization work, and
after weatherization, to verify the work and its effectiveness in meeting program goals.
My signature below certifies the information above is correct to the best of my knowledge. In addition it authorizes the
release of
income and utility usage records to the administering agency and the State of Utah. I authorize employers,
government agencies, (Soc.
Sec. Admin, Veterans Admin, Welfare Programs, etc.) to provide information concerning the
income statement above. Where
applicable I grant my permission for Rocky Mountain Power to pay the state of Utah for
the installation of approved measures and
administrative services in the dwelling I occupy, described above. I
acknowledge that I have received a copy of the Privacy Act.
Date:
Applicant’s Signature:
Agency Intake Approval:
Agency Editor Approval:
Date:
Application for Home Weatherization
INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED
A1
Date:
Updated: 06/2017
Home to be weatherized is: Owner Occupied Y N Title is recorded in the name of:
Rented or Leased: Y N Landlord Name &Address:
A signed Income Property Owner Weatherization Agreement must be included if the application is for a rented or leased dwelling.
Date of construction (if known): *Is the home a mobile/manufactured home? Y N
*All mobile homes require a copy of the “Title” to the home in the name of the applicant.
Is this dwelling scheduled or in the process for other housing rehabilitation such as (check on): Assist WVC
Green & Healthy Homes Assist
Habitat for Humanity Other
Are you interested in learning about any of the other programs offered by Utah Community Action Program if
so please specify which programs (circle one or more of the programs listed below):
HEAT Program Nutrition/Food Pantry Head Start Adult Education.
For more information call: 211 or 801-359-2444
Please provide as much information as you are able about the household’s income. We will not accept any
applications that are
missing the income portion completely and accurately filled out.
Earned Income Type
Y / N
Name of Recipient
Date Paid
Gross
Amount
How often is income
received? (weekly, bi-
weekly, twice monthly,
Employment
Y / N
Employment
Y / N
Self-employment
Y / N
Self-employment
Y / N
Unearned Income
Type
Y / N
Name of Recipient
Date Paid
Gross
Amount
How often is income
received? (weekly, bi-
weekly, twice monthly,
monthly)
Social Security, SSI, SSD
Y / N
Social Security, SSI, SSD
Y / N
Unemployment
Y / N
Pension
Y / N
Retirement
Y / N
Veterans Benefits
Y / N
Workers Comp
Y / N
Other:
Y / N
Explanation:
Mail/Fax/Email completed application to:
Utah Community Action Weatherization Program
850 West 1700 South Ste. 1
Salt Lake City, UT 84104
801-214-3215
Either Fax Or Email complete application to:
Fax: 801-214-3208 Email: weatherization@utahca.org
A2
Updated: 06/2017
Authorization to Release Customer Utility Information
Please include a copy of your current utility bills
Application Name:________________________________________________________________________________________
This form authorizes the Utah Weatherization Assistance Program to request and receive billing and utility
consumption
information for the
property listed below, from the specified Utility Provider(s). This information will be used
to determine
applicants’ energy burden and to measure the effectiveness of the Weatherization Assistance Program. This
form must be
signed by the Account Holder or Customer of Record for each Utility listed.
Physical Address: Mailing Address (If different):
Unit or Apt #: Unit or Apt #:
City:
State:
Zip: City:
State: Zip:
Information Specified
This authorization provides the Utah Weatherization Assistance Program, the right to request and receive information regarding
billing history* and all meter usage data used in the billing calculations from the Utility Provider(s) listed herein for
the
specified account (*billing history does not include the payment history or notices of discontinuation of service).
Duration
I authorize the Utility Provider(s) to provide the specified information for the period beginning twelve (12) months prior to the
account holder date of execution of this authorization, and ending twelve (12) months after the completion of Weatherization
Assistance, which completion is documented by the Weatherization Assistance Program’s Final Inspection and Partnership
Agreement.
Release of Account Information
I authorize the Utility Provider(s) to release the designated information to the Utah Weatherization Assistance Program. I
hereby release, hold harmless and indemnify the Natural Gas Provider and the Electricity Provider from any liability, claims,
demands, causes of action, damages, or expenses resulting from: any release of information to the Weatherization Assistance
Program pursuant to this authorization; the unauthorized use of this information by the Weatherization Assistance Program; and
any actions taken by the Weatherization Assistance Program pursuant to this authorization.
Natural Gas Release Electricity Release
Natural Gas
Provider:
Electricity Provider:
Name of Account
Holder: Name of Account Holder:
Service Agreement
No: Account No.:
Account
No.:
I authorize the Natural Gas Provider listed above to release
the
designated information to the Utah Weatherization
Assistance
Program as specified herein.
Account
Holder
Signature:
Date:
I authorize the Electricity Provider listed above to release
the
designated information to the Utah Weatherization
Assistance
Program as specified herein.
Account Holder
Signature:
Date:
DWS-HCD-W11
Rev. 03/03/2014
The Utah Weatherization Assistance Program
is administered by:
Utah Department of Workforce Services Housing
and Community Development Division
A3
Please Complete
Dominion Release
On Next Page
Authorization to Release Customer Information to a Third Party Agent
50863 07/18
This is a legal binding contract. This form must be signed by the account holder
or authorized agent for the account holder (such as CFO or City Manager).
Account:
Service Address:
I, __________________________________ of the above referenced account located at _____________________________________
do hereby authorize Questar Gas Company (“Dominion Energy”) to release the designated information below
To _____________________________________________
To _____________________________________________
This authorization provides the right to the designated Third Party Agent to request information regarding the items initialed below:
_______ Billing History (not including payment history or discontinuation of service) and all meter usage data used in the billing
________________calculations_of_the_specied_account
_______ _All_meter_usage_data_relating_to_the_specied_account
_______ _A_copy_of_the_bills_on_the_specied_account_mailed_to_the_third_party
_______ Deliver copies of any notices regarding termination of my natural gas service
This authorization will remain in full force and effect until date of ___________________ . If unspecied, this authorization will be limited
to a one-time request.
I, ____________________________________ declare that:
I am authorized to execute this document on behalf of the account record
__I_have_the_authority_to_nancially_bind_the_Customer_Record
__I_am_granting_the_Third_Party_Agent(s)_listed_above_the_right_to_request_the_release_of_specied_account_information
I understand that Dominion Energy reserves the right to verify any and all information provided pursuant to this authorization before
releasing customer data to the Third Party Agent.
I hereby release, hold harmless, and indemnify Dominion Energy from any liability, claims, demands, and causes of action, damages, or
expenses resulting from: any release of information to the Third Party Agent pursuant to this authorization; the unauthorized use of this
information by the Third Party Agent; and any actions taken by the Third Party Agent pursuant to this authorization.
Customer Signature: _______________________________________________
Customer Phone Number: ______________________________________ Email: ___________________________________________
Executed this __________________ day of _________________________ , 20 ________ .
I, Third Party Agent, hereby release, hold harmless, and indemnify Dominion Energy from any liability, claims, demands, causes of action,
damages or expenses resulting from the use of customer information obtained pursuant to this authorization and from the taking of any
action pursuant to this authorization.
Third Party Agent Signature: _________________________________________
Third Party Agent Company: _________________________________________
Third Party Agent Phone Number: ________________________________ Email: ___________________________________________
Executed this __________________ day of _________________________ , 20 ________ .
THIRD_PARTY_NAME/COMPANY
THIRD_PARTY_NAME/COMPANY
CUSTOMER_NAME_OR_AUTHORIZED_AGENT ADDRESS
1140 West 200 South | P.O. Box 45360 | Salt Lake City, UT 84145-0360 | 800-323-5517
Utah Community Action Weatherization
Utah Community Action Weatherization
801-214-3215
weatherization@utahca.org
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Updated: 06/2017
Mailing Address:
850 West 1700 South Ste. 1
Salt Lake City, UT 84104
Phone: 801-214-3215
Fax: 801-214-3208
Email: weatherization@utahca.org
Website: www.utahca.org/weatherization
Applicant Health And Safety Evaluation
Applicant Name: __________________________________________________________________________________________________
Client
Pre-Weatherization Assessment of Home Health and Safety: To be completed by the client and submitted
as
part of the Weatherization Assistance Application. Please answer all questions as accurately as possible.
1. Do you have mold or mildew issues in your home, or do you experience high humidity at any time of the year? Yes No
If Yes, please describe location & time of year
2. Is the basement or crawl space below your home frequently damp or wet? Yes No
3. Please check if you typically store any of the following items inside your home:
Gasoline
Kerosene
Paints
Solvents
Grease
Oil
Pesticides
Herbicides
Gas Powered Equipment
Space Heaters
Other:
None
4. Please check if any member of your household is experiencing any of the following symptoms:
Chronic headaches
Burning or watery eyes
Difficulty breathing
Chronic drowsiness
Asthma
Bronchitis
Dizziness Repeated Nausea
Other:
None
Answer the following if a member of your household is experiencing symptoms:
a.
Number of household member(s) experiencing symptoms
b.
List the age of the household member(s) experiencing symptoms
c.
During which season are symptoms most severe:
Spring
Summer Fall Winter
No difference
d.
Symptoms are most severe in household members who spend most of their time
Inside the home Outside Away from the home
No difference
5. Check if any of the following things have occurred at your home in the last 2 years:
New Construction
Extensive Remodeling
Painting
New Carpets
New Draperies, or furniture
Changes to your heating system
Changes to your Water Heater
New Wood Stove
Changes to your existing wood stove
6. Is there anything else about your home that you suspect may contribute to poor indoor air quality, excessive moisture,
or be a physical hazard to the occupants? Please explain:
7. I have answered the above questions to the best of my knowledge.
Applicant Signature: Date:
DWS-HCD-W11
Rev. 03/03/2014
The Utah Weatherization Assistance Program
is administered by:
Utah Department of Workforce Services Housing
and Community Development Division
SLC
A4
Updated: 06/2017
Dear Weatherization Client:
In 2011 the American Society of Heating Refrigeration Air Conditioning Engineers
(ASHRAE) concluded a study concerning healthy homes. Their recommendations to
the Department of Energy (DOE) dealt with the indoor air quality of homes that are
weatherized using DOE funds. The conclusions apply to both single family homes and
multi-family structures of three stories or fewer above grade, including modular or
manufactured homes. The study is only concerned about indoor air quality, not energy
efficiency.
Part of the weatherization includes testing such appliances as your furnace and water
heater, as well as the general air circulation of your home. AHSRAE requires that the air
supply be at a certain level not only for your health as an individual, but will also help
to reduce the problems of mold and other indoor air contaminants that cause poor
health.
If your home is tested and found to have inadequate air supply based on the ASHRAE
62.2 standards, it may be necessary for our crew to install a continuous exhaust fan in
your home. This fan will run at all times. Please understand that this is a requirement of
the Department of Energy. Beginning August 15, 2012 for your health and safety we will
follow this standard. Your energy auditor will be able to provide you with a
determination of the expected cost of operating this fan.
If your home is determined to be one that requires this fan, we must install it or we will
be unable to perform any weatherization work on your home. To that end we need
your signature below to verify you understand that this fan must be installed for your
health and safety and that you give your approval for us to do so. If you decline to
give your approval, we will have no alternative but to cancel any weatherization
activities in your residence.
I understand that the ASHRAE 62.2 standards may affect my home and require that a
continuous operating exhaust fan may be necessary for my health and safety. I
confirm that:
I Do I Do Not
approve of the installation of a continuous
operating
exhaust fan for the health and safety of my household.
Client signature
Date
Printed name
UTAH COMMUNITY ACTION IS PROUD TO BE AN EQUAL OPPORTUNITY EMPLOYER
A5
U.S. Department of Energy
OMB Approved 38 - R0198
PRIVACY ACT
Privacy Act Provisions
Under section 3(e)(3) of the Privacy Act 1974, 5 USC 552a(e)(3), each agency that
maintains a system of records shall inform each individual from whom it solicits
information of the authority which permits the solicitation of the information; whether
disclosure is voluntary; the principal purpose for which the information is intended to be
used; the routine uses which may be made of the information; and the consequences, if
any, resulting from failure by the individual to provide the requested information. This
statement is required by the Privacy Act to be furnished prior to the collection and use
of the information requested on the application for weatherization. You may retain this
statement for your records.
Program Authority
The specific authority for the maintenance of weatherization client information is sections
416 and 417 of the Energy Conservation and Production Act, Pub. L. 94-385. These
sections direct the
U.S. Department of Energy (DOE), which is a sponsor of this program, to monitor the
effectiveness of this program, and to require a weatherization agency implementing this
program to keep records for DOE monitoring.
The State of Utah Weatherization Assistance Program is the recipient of weatherization
funds from both DOE and the Department of Health and Human Services, and is required
by 10 CFR 440 to document the eligibility of every dwelling unit weatherized and to
maintain records for program monitoring and evaluation.
Voluntary Disclosure
Your responses to the request for information on the Weatherization Assistance
Application, Authorization for Release of Information form, and Fuel Information form are
entirely voluntary.
Principal Purpose of Information
The information will be used by the local weatherization agency to implement the
weatherization program. It will be used by DOE to monitor the effectiveness of the
program.
Routine Uses
The information, which you provide, will be used in monitoring and evaluating the
effectiveness of the weatherization program. In addition, the information may be used in
investigative, enforcement, or prosecutorial proceedings.
Effects of Not Providing Information
Should you decline to provide the information requested on the application form, your
dwelling will not be considered for weatherization assistance. However, you need not
sign the Billing History Release Authorization form in order to be considered for
weatherization assistance.
08/2014
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Weatherization Application Checklist (Utah Community Action)

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