Weatherization Application
Community Resources Weatherization Program can help you save on energy bills- including rental properties!
Questions? Call us!
If someone in your household has a disability, then income over the above amounts may not disqualify you from services. You must be a resident of the state of West Virginia to apply. Preference may be given to people over 60 years of age, families with one or more members with a disability, families with children under 5, and families on welfare. If you have any questions regarding the form or the required documentation, please call 304.485.5525 or visit https://www.benefits.gov/benefit/580.
Attention:
The following is a complete application for Weatherization. Please answer each question and carefully read any instructions, notes, or comments as you move through the application. Failure to complete the application fully will result in automatic deferment until the application is completed and all required documents are signed and submitted. If you need assistance completing the application, please submit the "general information" section, then call Community Resources at 304.485.5525 to schedule an appointment with a case manager.
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Email
example@example.com
Name
First Name
Last Name
Additional Household Members: Names
Applicant Gender
Male
Female
Other
Additional Household Members: Gender
Applicant Birthday
-
Month
-
Day
Year
Date
Additional Household Members: Birthdays
Applicant Social Security Number
Additional Household Members: SS Numbers
Applicant Family Relationship
Head of Household
Mother
Father
Daughter
Son
Foster Parent
Foster Child
Grandma
Grandpa
Grandchild
Partner
Spouse
Aunt
Uncle
Sister
Brother
Former Spouse
Other
Additional Household Members: Family Relationship
Are you currently living in the household?
Yes
No
Does anyone in the household have a disability?
Yes
No
Unsure
If yes, who in your household has a disability?
What is your marital status?
Married
Divorced
Single
Widowed
Separated
Partner
What language(s) do you speak most frequently?
English
Spanish
Other
What is your physical address?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is your mailing address different from your physical address?
Yes
No
If yes, what is your mailing address?
Phone Number
-
Area Code
Phone Number
Household Type:
Grandparent(s) raising grandchild(ren)
Multiple adults (living with children)
Multiple adults (no children)
Single parent female (living with children)
Single parent male (living with children)
Single person (living alone)
Single person (living with others)
Single person (living with partner)
Two parent household (living with children)
Housing Type
Homeless
Incarcerated
Living with friends or family
Own
Rent(Assisted)
Rent(unsubsidized)
Transitional/shelter
Applicant Highest Level of Education Completed?
0-8
9-12 Non-graduate
High school graduate/GED
12+ some post secondary
Some college/certificate/trade
2-4 year college graduate
Post graduate degree
Additional Household Members: Highest education level completed
Applicant Military Status
Active Military
Veteran
None
Unknown
Additional Household Members: Military Affiliation
Applicant Work Status
Employed full-time
Employed part-time
Retired
Not in labor force
Unemployed for over 6 months
Unemployed for less than 6 months
Migrant Seasonal/Farm Worker
Additional Household Members: Work Status
Health Insurance
Medicaid
Medicare
Employment Based
Military Healthcare
Direct-Purchase
Applicant Race
White or Caucasian
Black or African American
Bi-Racial or Multi-Racial
Asian
Middle Eastern
American Indian or Alaska Native
Pacific islander or Native Hawaiian
Other
Additional Household Members: Race
Applicant Ethnicity
Hispanic or Latino
Non-Hispanic or Latino
Additional Household Members: Ethnicity
Monthly Income Sources for Each Household Member
Employment Earnings
No Income
Black Lung
Educational Assistance
Estates/Trusts
Interest/Dividends
Miscellaneous
Outside Assistance
Pension/Retirement
Public Assistance
Rental Income
Royalties
Social Security
SSI
State Assistance
Unemployment
TANF
Veteran's Benefits
Non-cash Benefit
IS General Assistance
Worker's Compensation
Please add together monthly income sources for each household member and type total monthly income below:
Guide to Recording Monthly Income Sources
In the space provided above, please list all of your selected monthly income sources and their amount in $$. Next, add the income source amounts together to find your TOTAL monthly income. Example: Alimony: $300 + Employment Earnings: $1,000 = Total Monthly Income: $1,300.
Proof of Income for ALL working household Members: (Includes Pay Stubs for the last month, Social Security Award Letters, Child Support Documentation, etc.)
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Residence
This section is intended to gather more information about your current place of residency as well as your heating and cooling providers. Please answer each question to the best of your ability and ONLY answer questions that are applicable to your household.
Structure
Brick
Masonary
Mobile Home
Multi-Unit
Wood Frame
Home # of Stories
1
1.5
2
3
4
Type of Dwelling
Site Built (built from bottom up)
Modular Home (no wheels)
Doublewide
Mobile Home
Mobile home with add-on
Row House
Multi-Family Unit (5 or more homes in 1)
Duplex (2 homes under 1 roof)
3 or 4 unit rental
Shelter
Transitional
Other
Do you live in a
City/Town
Suburb
Rural Area
Year home was built (or best estimation)
Are there smokers in your home?
Yes
No
If yes, how many?
Was the home previously weatherized?
Yes
No
If so, when?
If previously weatherized, was the dwelling subsequently damaged by fire, flood, wind, or any other event?
Yes
No
If yes, when?
Do you use space heaters?
Yes
No
If yes, how many?
Does the government assist with the rent or mortgage payment?
Yes
No
How much is monthly rent or mortgage payment?
In $$
Primary Heating
*
Electricity
Fuel Oil
Kerosene
Natural Gas
None
Other Fuel
Propane/LPG
Wood
Who is your primary heating vendor
*
Account #-
Secondary Heating (*if applicable)
Electricity
Fuel Oil
Kerosene
Natural Gas
None
Other Fuel
Propane/LPG
Wood
Who is your secondary heating vendor
Account #-
Cooling Energy
Electric
None
Vendor
Account #-
How do you cool your home?
Central Air
Window/Wall Unit
None
How much is your monthly energy bill?
In $$
Please upload documentation of your most recent Gas bill:
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Please upload documentation of your most recent Electric bill:
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Please provide detailed directions to your home:
*please note: directions can/should include roads, highways, and major landmarks that lead to your dwelling
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Required Documents
In order to fully process your Weatherization application, we need the following forms filled out/signed for our records: Weatherization Consent form, Customer Consent form, Income Verification form, 0 Income Affidavit*, Landlord Agreement form**
Please Note:
*0 Income Affidavits only need to be filled out by household members over the age of 18 who do not have income. **Landlord Agreement forms are only necessary for applicants currently in a rental agreement. Please have your landlord fill out the document and return it to your local Community Resources office.
Preference for signing documents:
Email me: sign electronically online through Docusign
Mail me my documents
Sign documents at my local Community Resources office
Select a Community Resources, Inc. Address by County:
Calhoun- 258 Court Street Grantsville, WV 26147
Doddridge-1163 WV RT 18N Suite 1 West Union, WV 26456
Gilmer-102 East Main Street Glenville, WV 26351
Jackson-206 Stone Drive Ripley, WV 25271
Pleasants-212 Second Street St. Marys, WV 26170
Ritchie-633 South Spring Street Harrisville, WV 26362
Roane-811 Madison Ave. Room 22 Spencer, WV 25276
Tyler- 308 East Street Middlebourne, WV 26149
Wetzel-21 Rosary Road New Martinsville, WV 26155
Wirt-90 Senior Circle, Room 1 Elizabeth, WV 26143
Wood-1037 Market Street Parkersburg, WV 26101
Phone Numbers by County:
Calhoun- (304) 354-9265
Doddridge- (304)-873-3439
Gilmer- (304) 462-8698
Jackson- (304) 373-0313
Pleasants- (304) 684-3461
Ritchie- (304) 643-2332
Roane- (304) 927-4632
Tyler- (304) 758-0696
Wetzel- (304) 455-2701
Wirt- (304) 275-4306
Wood- (304) 485-5525
Are you sure you're ready to submit? Please click the back button if you wish to review your application before hitting "Submit".
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