Weatherization Assistance Application

Assistance Application

Weatherization
721 SE 3rd, Suite D
Pendleton, OR 97801
541-276-1926 | 800-752-1139

Serving Gilliam, Hood River, Morrow, Sherman, Umatilla, Wasco, and Wheeler counties
All fields marked with an asterisk (*) are required.

Incomplete or unsigned applications will be returned to you, by mail, for completion.
Name: *

First Name Last Name
Phone Number *
Email: *
example@example.com
Physical Address: *

Street Address

Street Address Line 2

City State

ZIP Code
Is your Mailing address the same as your Physical address? *

Yes No
Mailing Address:

Mailing Address

Mailing Address Line 2

City State

ZIP Code

Number of household members: *
List ALL household members here: *

Complete a row on this table for EACH member of your household (including yourself): *

	Full Name	Date of Birth	Primary Language	Gender	Race	Ethnicity	Oregon Tribe	Highest Grade	Veteran?	Home-bound?	Non-Cash Benefits	Disabled?
1 Self
2
3
4
5
6
7
8
9
10

Do you receive Energy Assistance? *

Yes No
Do you receive SNAP Benefits? *

Yes No
Have we weatherized your home before? *

Yes No
If 'Yes,' when? *

Home Information *

Mobile Home House Duplex Triplex
Size of home, in square feet *
Which are you? (Applicant's name must be on the title or the home will be considered a rental.) *

Renter Home Owner - Landlord Home Owner - Resident
Landlord's Name *

First Name Last Name
Landlord's Phone Number *

Area Code Phone Number
Once you 'Submit' this application you will recieve an email with an attached form that, if you are a Renter, you will need to have your Landlord fill out and return to CAPECO.
If you are a RENTER and did NOT provide an email address - Please contact CAPECO Weatherization and ask for the Landlord and/or Authorized Agent Certification form. You will need to have your Landlord or their Authorized Agent fill out the form and return it to CAPECO in order to have your application considered for Weatherization.
Year House was built: *
Length of time, in years, that you have lived at this address: *
HOME OWNER CERTIFICATION

I, {name}, certify that I am the owner of the address listed on page one of this application.

I have attached the following Documentation of Ownership:current Property Tax Statement or Deed or Contract of Sale.

I further grant permission to allow weatherization and base load measures to be performed on the property listed on page one of this application in accordance with the following conditions: The Energy Services Department of CAPECO will determine the measures to be installed based on anticipated energy savings, cost effective criteria and State Regulations. Due to limited funding, the Weatherization Program may only be able to install SOME of the listed measures.

1.Air infiltration
2.Furnace retrofit
3.Wall insulation
4.Ceiling insulation
5.Floor insulation
6.Duct sealing
7.Duct insulation
8.Entry door repair/replace
9.Window repair/replace
10.Water pipe insulation
11.Ensure proper ventilation
12. Combustion safety

Window measures DO NOT include cosmetic treatment of trim.

I understand that the property cannot be, and is not currently, for sale, nor is it designated for acquisition or clearance (foreclosure) by federal, state or local programs.
Upload Documentation of Ownership below:
- Current Property Tax Statement, or
- Deed, or
- Contract of Sale
Upload Documentation of Ownership here

Browse Files
File types accepted: pdf, jpg, jpeg, png Cancel of
Signature *

Applicant's Signature Clear
Date

Month Day Year
Printed Name of Owner: {name}

Street Address: {streetAddress}

Mailing Address: {mailingAddress}

Phone Number: {phoneNumber}

APPLICANT DISCLAIMER AND RELEASE

I understand that these programs are voluntary; if I choose to apply for weatherization assistance, I must provide all required information. During application processing I may be asked for more information in order to determine my eligibility.

I understand that the information I provide to complete this application will be used to determine and verify my eligibility for weatherization assistance and for the purposes of referral, research, evaluation, and analysis.
I understand that if I feel my application was unjustly denied or not processed in a timely manner, I may be entitled to a fair hearing if requested within 30 days of the completion date of the application or date of denial. Any such request for a hearing must be in writing and delivered or mailed to the local service provider.

In addition to any appeal rights from such hearing granted by the local service provider, I may contact the Oregon Housing and Community Services Department (OHCS) within 30 days of the service providers hearing decision to request that OHCS review the decision for material deficiencies.

The request for OHCS review must be in writing and delivered by email to energyservices@oregon.gov or mailed to 725 Summer St NE Suite B, Salem OR 97301. Review by OHCS, and the manner thereof, is at the sole discretion of OHCS.

I understand that the property cannot be, and is not currently, for sale, nor is it designated for acquisition or clearance (foreclosure) by federal, state or local programs.

I declare, under penalty of perjury, that the information I provided to complete this application is true and correct.

My signature gives consent for other offices of the state and federal governments, their designated subcontractors, and the utility(ies) or home energy supplier(s) identified in this application to share information related to my application including information about my account(s) including, but not limited to, account number, account name, service address, annual usage or consumption, and annual costs. I agree to hold harmless and/or release such organizations from and against any claims, losses, demands, damages, or liability of any kind caused by or allegedly caused by such disclosure.

I authorize my utilities and/or my fuel suppliers/vendors to release my account information to OHCS and to the service provider for the purposes of providing weatherization assistance. I am the account holder or the customer’s authorized agent for the utility, fuel supplier, and/or fuel vendor service accounts(s) identified in this application.

I understand the information I provide will be used to determine and verify my eligibility for weatherization. I understand that if I feel my application was unjustly denied, I may be entitled to a fair hearing if requested within 30 days of the date of denial. If I feel I have been discriminated against by the local provider, I may appeal to Oregon Housing and Community Services.

My signature gives consent for offices of the state and federal governments, their designated subcontractors, and the utilities or home energy supplies to share information, including information about my account.
Applicant's Signature *

Clear
Date

Month Day Year
Additional Applicant Signature

Clear
Date

Month Day Year

Utility Release of Information Form

I hereby authorize the following Utility Provider(s) to release my account information to CAPECO. It is my understanding that this information will be used for Energy Assistance or Weatherization Services. All information will remain confidential.
Electricity Utility Name:
Account Number for Electricity Utility:
Secondary Utility Name:
Account Number for Secondary Utility:
Printed Consumer's Name:
Home Phone:
Service Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Applicant's Signature *

Clear
Date

Month Day Year
Incomplete or unsigned applications will be returned to you, by mail, for completion.
Should be Empty: