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Weatherization Assistance Program Inquiry Form
Fill out form below to request a Weatherization Application.
Household gross income must be at or below 200% of federal poverty level to qualify for the Weatherization Assistance Program.
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* Indicates required question
First and Last Name:
*
Your answer
Address
*
Your answer
City:
*
Your answer
State: PA (must be a resident of Bucks County, PA)
*
Your answer
Zip/Postal Codes:
*
Your answer
Best Phone number to reach you:
*
Your answer
Email
Your answer
How did you hear about us?
*
Word of mouth
Social Media
BCOC Program
I received a mailer
Required
How long have you lived in your home?
Your answer
How many people reside in the household?
Your answer
Does anyone living in the home receive any of the following?
Section 8/HUD Housing
SNAP
LIHEAP
TANF
National School Lunch Program
What type of fuel is used to heat your home?
Your answer
How is your home heated?
Forced Hot Air (air blows through vents)
Forced Hot Water (radiators or baseboard pipes)
Other:
Does the heater work?
Yes
No
Clear selection
Are there any roof leaks?
If yes, please give details.
Your answer
Do you have a basement?
(If yes, please indicate if it gets damp/wet.)
Your answer
Is there any evidence of mold/moisture in your home?
(Please specify where)
Your answer
Do you have any structural damage (holes in walls, incomplete construction, sagging floors or ceilings, etc.)?
If yes, please specify.
Your answer
Is there anything in your home that would prevent staff/contractors from moving around easily?
If yes, please specify.
Your answer
Any additional comments or important information:
Your answer
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