Weatherization Intake Determination
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Email Address
Phone Number (xxx)xxx-xxxx *
First Name *
Last Name *
Address *
City *
State *
Zip Code *
How long have you resided at this current address?   Years *
How many people live in your home? *
Do you own or rent your home? *
Are there children under 5 years of age? *
Are you a Crisis Client? *
Are you a Veteran? *
Are you disabled? *
Do you receive Social Security Benefits? *
Do you receive SSI? *
Do you receive Public Assistance/TANF? *
Does your home have any of the following issues?
Knob and Tube Wiring *
Mold/ Moisture *
Leaking Roof *
Does your household meet the annual income eligibility requirements? *
Estimated Total Annual Gross Amount? *
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