Form Weatherization Program Application

Step 1 of 5

Has anyone in your household applied for, or received Energy Assistance?*

Yes

How long have you been at this address?*

Landlord information

Landlord/Legal Owner’s name?

Phone

Address

Street Address City State / Province / Region ZIP / Postal Code

Has the home been weatherized in the past 15 years using Federal Funds?

Yes

Power Bill*

Max. file size: 512 MB.

Gas Bill (If Applicable)

Max. file size: 512 MB.

CLIENT DISCLAIMER: by signing this form I certify that all information provided is accurate and true to the best of my knowledge. I herby authorize the release of all personal information and records, financial or otherwise collected from this application to Oregon Housing and Community Service Department, its agents, and subgrantees for any legitimate purpose including, but not limited to the purpose of deciding eligibility for any and all utility assistance programs available and for reporting associated with those assistance programs.

Applicant Signature*

Date*

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Weatherization Program Application

Household Members

Landlord information

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