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Application for Energy & Rehab Assistance

Applicant Information
First Name *
Last Name *
Address Line 1 *
City *
State/Province *
Postal Code *
Address Line 1
Postal Code
Do you or any member of the household have an existing health problem that may become elevated by the weatherization measures that may be performed on your home?
Home Heating System
I heat my home with:
Type of heating system
Home Information (Please select only one of the four options below)
How many units are there in building?
Water Heater
Air Conditioning Type
Is your household currently on the LIHEAP Heating Assistance Program?
Owner or Renter Agreement
If you rent your home, please provide contact information for your landlord
Application Certification

I, the applicant, declare that I understand the eligibility requirements for energy conservation assistance. The information provided by me to establish my eligibility is true and accurate to the best of my knowledge. I consent to the independent verification of this information by SENDCAA or its governmental funding source. I further consent to the inspection of my house by SENDCAA personnel for the purpose of estimating, completing and inspecting the energy conservation project.

I, the applicant, grant permission to SENDCAA or its designee to inspect heating fuel and utility billing records for my home for up to five years before and subsequent to the performance of the energy conservation work for the sole purpose of obtaining data required to evaluate the energy conservation effectiveness of the project, and direct the pertinent fuel and utility companies to provide records to SENDCAA or its designee.

I, the applicant, grant SENDCAA or its designee permission to use photographs of materials installed on my home and grant permission to forward photographs of materials installed on my home to funding sources for use in promoting the weatherization assistance program.

I, the applicant, grant SENDCAA permission to request proof of or verify my household income and/or LIHEAP eligibility with the social service agency if needed to process my application.

I, the applicant, understand that any and all information regarding my application will be kept confidential. All application and eligibility information will be protected against indiscriminate access by SENDCAA staff, and will not be made available for public review.

By typing my name, I agree to the above statements
First Name *
Last Name *