Housing and Energy (Weatherization) Sign Up Form- For Customers
Fill this form out to be put on the waiting list to receive an application and services.

When you get close to the top of the waiting list, we will contact you to make an appointment to complete an application. For more information, please contact our office at 315-788-4388.  

*This is not an emergency program. For all housing and energy emergencies, please contact your local Police Dept./Fire Dept. or the appropriate services such as the Department of Social Services.

Sign in to Google to save your progress. Learn more
How did you hear about the program? *
First and Last Name *
Address (Street, Apt #) *
City *
Please add your email address *
Mailing Address (if different)
Phone Number(s) *
Select Ownership Type *
Select Type of Home *
If you selected 2+ Unit Building, please state the total number of units.
If you rent, please state the landlord's info (Name/ Address/ Phone Number)
Eligibility *
Select all that you receive. If you receive at least one of the following, you are automatically eligible. If not, it's determined based on income.
Required
Household Size *
Gross Income per Year *
This is the gross (before tax) income for everyone in the household combined.
Heating Source *
Select all that apply
Required
Number of household members who are... *
0
1
2
3
4 or more
60 years of age or older
Children under 18
Disabled
Does your roof leak? *
Have you or has the property ever received weatherization services before? *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Community Action Planning Council. Report Abuse
Google Forms