CPCA Weatherization Application

INTRODUCTION & REQUIRED DOCUMENTS

The mission of the North Carolina Weatherization Assistance Program is to improve household energy efficiency and energy related health and safety, for low-income North Carolina residents. The program focuses primarily on serving the elderly, the disabled, families with young children, high-energy users, and the heavily energy burdened. The Heating and Air Repair and Replacement Program focuses specifically on the repair or replacement of unsafe, inoperable, and inadequate heating and cooling systems. Weatherization assistance is available to low income residents living in single-family houses, apartments, condo miniums, and mobile homes. You DO NOT have to own a home to be eligible. Renters MUST have written permission from the property owner before services are rendered. Eligibility criteria may vary between programs. Multifamily units cannot exceed 4 connected units and/or 5 buildings total on property. Each unit must be individually metered.

What the Weatherization Assistance Program (WAP) and Heating and Air Repair and Replacement Program (HARRP) do:
- Evaluates homes for energy-related efficiency and safety upgrades
- Insulates attics, floors, and walls as needed
- Makes minor repairs to address energy-related health & safety issues
- Repairs or replaces heating/cooling systems if required
ELIGIBILITY DOCUMENTATION REQUIREMENTS
**Provide ALL that apply to each household member. Provide a copy of awards letter or printout for all that apply**

HOUSEHOLD INCOME DOCUMENTATION

Income is defined as cash receipts earned and/or received before taxes or deductions. Income includes money, wages and salaries before deductions, regular payments from social security, railroad retirement, and unemployment compensation, strike benefits from union funds, worker’s compensation, veteran’s payments, training stipends, alimony and military family allotments. Private pensions, government employee pensions (including military retirement pay), and regular insurance or annuity payments; dividends, interest, bonds, and other investments (including 1401(k), 403(b), SEP, ESOP, net rental; income, net royalties, periodic receipts from estates or trusts and net gambling or lottery winnings.
- Government issued photo identification copy ( for all adult occupants )
- Complete Income Tax Returns (including W-2 copies) for all required to file for past year
- Pay check stubs for last 2-months (including YTD pay) and final check stub from each job ended in last 12-months
- Unemployment benefits history for last 12-months
- Proof of Social Security numbers for ALL occupants (i.e., card or printout of number from Social Security office)
- Social Security Administration benefits history (SSA and SSI) for last 12-months (attach Social Security printout)
- Veterans Administration benefits history for last 12-months
- Disability Pension income history for last 12-months
- Retirement, pension, IRA, dividend, or annuity income history for 12-months
- Alimony payment history for last 12-months
- Rental property income history for last 12-months
- Profit & Loss Statements for all self-employed household members for last 2-years (professionally prepared)
- Notarized statement for zero-income
  All other income history for each household member for last 12-months
DWELLING OWNERSHIP DOCUMENTATION
- Parcel Tax Record Card issued by the county tax administration within last 30-days
- Property Tax Notice issued by the county tax administration within last 12-months
- Deed recorded and stamped at the county court house in the county where the dwelling is located
- NC DMV issued motor vehicle Certificate of Title for a mobile home or Bill of Sale (exceptions may apply)
DWELLING FUEL/UTILITY CONSUMPTION HISTORY
- 12 months fuel/energy history for each fuel/utility provider serving the dwelling (must include kilowatt hours; meter reading date, therms/CCF, number of days in the cycle and billing amount). Printout must include account name and account number.

Income

List All Persons Living in Home AND Their Income
I Live *

Alone With Others As Completed Below (Household Members 1-5)
Including Self, How Many Live In The House

Other Household Member 1
Name *

First Name Middle Name Last Name Suffix
Date of Birth

Month Day Year
Date
Social Security Number
ALL Income Sources with Duration (ie. $1234 per month since 5/2018 from Cheers)

Other Household Member 2
Name *

First Name Middle Name Last Name Suffix
Date of Birth

Month Day Year
Date
Social Security Number
ALL Income Sources with Duration (ie. $1234 per month since 5/2018 from Cheers)

Other Household Member 3
Name *

First Name Middle Name Last Name Suffix
Date of Birth

Month Day Year
Date
Social Security Number
ALL Income Sources with Duration (ie. $1234 per month since 5/2018 from Cheers)

Other Household Member 4
Name *

First Name Middle Name Last Name Suffix
Date of Birth

Month Day Year
Date
Social Security Number
ALL Income Sources with Duration (ie. $1234 per month since 5/2018 from Cheers)

Other Household Member 5
Name *

First Name Middle Name Last Name Suffix
Date of Birth

Month Day Year
Date
Social Security Number
ALL Income Sources with Duration (ie. $1234 per month since 5/2018 from Cheers)
As the applicant, I certify that the preceding information is true and correct to the best of my knowledge. *

Clear
Today's Date *

Month Day Year
Date

Landlord Information

(if renting)
Are you renting (skip and go to the next page if answer is No) *

Yes No

Landlords Information
Landlords Name

First Name Middle Name Last Name Suffix
Phone Number

Area Code Phone Number
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Today's Date *

Month Day Year
Date
Click Here for Landlord/Tenant Agreement

Privacy Act Notification & Acknowledgment
It is the policy of Central Piedmont Community Action, Inc. to ensure that any information obtained from applicants is kept confidential. Applicant acknowledges receipt of CPCA's Privacy Act. Signature of Applicant *

Clear
Signature of CPCA Staff Upon Receipt

Clear
Today's Date *

Month Day Year
Date

Self-declaration of Income Eligibility for Weatherization Services & Information Release Authorization
Today's Date *

Month Day Year
Date
As of the date above, the total household income for my family during the preceding 12 months is estimated to be *
As of the date above, the number people living in the home is *
For 2020, Adapted from WAP Notice 20-3

Household income set at 200% of the federal income eligability guidlines for household sizes are 1 person is $25,520; 2 people is $34,480; 3 people is $43,440; 4 people is $52,400; 5 people is $61,360; 6 people is $70,320; 7 people is $79,280; 8 people is $88,240; for each additional member add: $8,960.

I understand that federal income eligibility guidelines above have been set for CPCA Weatherization applicant eligibilty. My household size of {asOf} had an estimated income for the previous 12 months of {asOf77}. To the best of my knowledge all sources of income for my present household does not exceed the income guidelines above during the past 12 months. No one else in my household has applied for CPCA Weatherization services in this program year.

I give permission to Central Piedmont Community Action Inc., to secure whatever information is necessary for the purpose of verifying my household’s income disclosed above and /or from any additional sources the agency may discover on its own.

I further give my permission to Central Piedmont Community Action, Inc. to discuss the full particulars of my household situation with any agencies, offices, groups, or organizations that CPCA believes may assist with the resolution of my household issues and concerns. I authorize these same agencies, offices, groups, or organization to disclose what they know about me and my household to Central Piedmont Community Action, Inc.
Applicant Signature Attesting Above *

Clear

Weatherization Program "No Income" Statement

(if applicable to adult household member)
Today's Date *

Month Day Year
Date
Name

First Name Middle Name Last Name Suffix
I verify that I am unemployed as of {todaysDate106}.
I am (check all that apply)

Seeking Employment Going to School

I receive assistance from (complete all that apply) *

Monthly Total

Housing

Food Stamps

Family Member(s)

Child's Father/Mother

Partner

Other

Receive No Assistance, enter 0

Monthly Assistance Received Total *
Signature of Applicant *

Clear
Signature of CPCA Staff Upon Receipt

Clear

Weatherization Program

Utility Information Release Authorization
Name of Electric Company *
Account Number *
Name on Account *
Account Address (exactly like it is on your electric bill) *
Phone Number *

Area Code Phone Number
Email
example@example.com
I, {nameOn144} (Account Holder name), authorize Central Piedmont Community Action, Inc, the North Carolina Weatherization Assistance Program ("NCWAP") and its representatives to obtain my household energy usage information from {nameOf143} for the purpose of tracking my Pre- and Post- Weatherization energy data for the period beginning {todaysDate147} until the most recent. I understand that NCWAP is not responsible for the status of my account.
Client Signature *

Clear
Account Holder Signature (if different from Client)

Clear
Today's Date *

Month Day Year
Date

Permission to Enter Premises
To the Dwelling Owner:

Your dwelling has been approved for weatherization services under the Weatherization Assistance Program (WAP). At the bottom of this page is a form granting you permission for CPCA to enter you dwelling to perform an energy audit in order to determine what work needs to be done to your building to decrease energy usage.

Permission to Enter Premises:

I, as the owner/authorized agent of the dwelling located at {accountAddress} have read and understand the above and hereby grant permission for the representatives of CPCA to enter this premises for the purpose of conducting and energy audit for the residents.
Owner/Agent Signature *

Clear
If Agent, Your Title and Company
Today's Date *

Month Day Year
Date

Airtable Database Permission

Chatham County Residents Only
By signing this form, I hereby authorize Central Piedmont Community Action, Inc (CPCA) to enter my information into a collaborative project management database (Airtable).

Airtable is a collaborative initiative in Chatham County with multiple organization that work on different aspects of minor home repair, home modification, weatherization, and additional services. This is an effort to more effectively serve the residents of Chatham.

I understand that this release of personal information does not mean it will be sold to any third party, nor does it mean faster service delivery. By having my information in this database, I understand another organization may call or contact me about service delivery, my project may be taken on by a different organization, or by multiple.
Signature of Applicant *

Clear
Signature of CPCA Staff Upon Receipt

Clear
Today's Date

Month Day Year
Date

NC Weatherization Applicant Eligibility Hearing & Appeals Process
1. If you disagree with our decision, you have sixty (60) calendar days from the date of the letter to ask for a hearing.

2. Your appeal must be made in writing to the Weatherization Coordinator at the agency.

3. The agency will schedule a hearing within ten (10) business days of your request.

4. The agency will render a final decision to you in writing within ten (10) business days of the hearing.
Should be Empty:

Weatherization Application

Income

Landlord Information

Privacy Act Notification & Acknowledgment

Self-declaration of Income Eligibility for Weatherization Services & Information Release Authorization

Weatherization Program "No Income" Statement

Weatherization Program

Weatherization Program / Energy Auditor

Permission to Enter Premises

Airtable Database Permission

NC Weatherization Applicant Eligibility Hearing & Appeals Process