COMMUNITY ACTION PROGRAM REGION VII, INC. Phone: 701-258-2240

COMMUNITY ACTION PROGRAM REGION VII, INC. Phone: 701-258-2240 2105 Lee Avenue, Bismarck, ND 58504-6798 Application No.

WEATHERIZATION & County FURNACE/WATER HEATER REPAIR/REPLACEMENT APPLICATION

Name (Last, First, MI): Telephone No.: Message Phone:

Address: City: State: Zip Code:

Directions to Home (If no street address):

OCCUPANCY STATUS Years at Address: Square foot area of dwelling: Rent Own *Skip this line if owner Name of Landlord: Rental Agreement on File? Do not include lot rent NO YES DWELLING TYPE (check all that apply) FUEL HEATING SYSTEM Single Family Home Wood Frame Oil Hot Water-Boiler Mobile Home/Trailer Stucco Natural Gas Forced Air 2 - 4 Family Units Brick LP Gas (Propane) Space Heater 5 or more Family Units Other Coal Floor Furnace Wood Wall Furnace One Story Electricity Other 1 1/2 Story Other 2 Story 3 or more Stories Number of smoke detectors Air Conditioning

Main Energy Supplier Energy Costs ($) Per

OFFICE USE ONLY Fuel Assistance OMB Poverty 150% In-Kind DO NOT WRITE IN Referral Guidelines 200% Source______SHADED AREAS Other Referral $______$______APPLICANT CERTIFICATION I, the applicant, declare that I understand the eligibility requirements for 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 the authorized agent of the agency or its governmental funding source. I further consent to the inspection of my house by authorized personnel of the agency for the purpose of estimating and performing the necessary work. (For Weatherization) I also grant permission to the administering agency 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 weatherization work for the sole purpose of obtaining data required for evaluation of energy conserving effectiveness of the work done and direct the pertinent utility and fuel companies to make records available to the administering agency or its designee.

______Signature of Applicant Spouse Name Date Signed AGENCY REVIEW Application Status: Approved Disapproved - Reason______

______

By ______Staff Name Date______

Weatherization Furnace

h:\common\abdullah\weatherizationapplicati on.doc Updated 2/09 COMMUNITY ACTION UNIVERSAL INTAKE FORM, 2105 Lee Avenue, Bismarck, ND 58504-6798

Date______/______/______CAA Program ______ID/App #______Staff______

Head of Household______SS# ______-______-_____

Address ______Relation Race Education (Ed.) Medical Coverage Farmer C= Child W= White A= 0 to eight MC= Medicare MI= Migrant City ______State______O= Other A= Asian B- 9-12 (non grad) MA= Medicaid S= Seasonal Zip ______Telephone______P= Parent B= Black C= HS Grad or GED N= None F= Farmer Total Persons in Household (Circle Number) R= Relative H= Hispanic D= 12+ Post Secondary U= Unknown NF= Not Farmer 1 2 3 4 5 6 7 8 9 10 11 12 13 14 S= Spouse N= Native American E= Unknown Y= Yes/Other U+ Unknown Please use the key to the right to O= Other F= College Degree complete the following information.

Social Birth Disabled Race Food Medical Last Name First Name Security Relation Gender Ed. Farmer Vet. Date (optional) (optional) Stamps Coverage Number 1 Above Head M / F Y / N Y / N Y / N

2 M / F Y / N Y / N Y / N 3 M / F Y / N Y / N Y / N

4 M / F Y / N Y / N Y / N

5 M / F Y / N Y / N Y / N 6 M / F Y / N Y / N Y / N

7 M / F Y / N Y / N Y / N

8 M / F Y / N Y / N Y / N HOUSEHOLD INCOME INFORMATION

Amount of Income Source(s) of KEY Amount of is for what Pay Income Household Member Occupation Income Period? (List all that apply Pay Period Source of Income (See key to right) using key to right A= Weekly A= Employment B= Bi-Weekly B= Unemployment C= Monthly C= Soc. Security D= Annually D= TANF E= General Assistance F= SSI/SSD G= Food Stamps H= Medicaid I= Other Total Income: ______per ______

HOUSEHOLD CHARACTERISTICS Household Type (check one) Housing (check one)

_____ Female Single Parent _____ Homeless (with roof) _____ Male Single Parent _____ Homeless (no roof) _____ Two Parent _____ Homeless _____ Couple _____ Owner _____ Single _____ Renter _____ Other _____ Unknown _____Other Site: Rent Amount: ______County______Subsidized (circle one): Yes / No

Staff Notes: Updated ADDITIONAL COMMENTS:

2.094/07

OFFICE USE ONLY STAFF NOTES/ADDITIONAL FOLLOWUP: