Weatherization Application

Please fill out for each member of the household

	Full Name	Relationship to Head of Household	Social Security Number	Race	Ethnicity	Age	Date of Birth	Gender
Head of Household
Household Member
Household Member
Household Member
Household Member

Please fill out for each person in the household that receives income

	Name of Household Member with the Income Source	Yes/No	Monthly Amount
SSI
SSDI
SSA (Retirement SS)
Earned Income/Wages
Child Support
Cash Assistance (DHHS)
General Assistance (Tribal)
VA Disability/Income

Please fill out for each person in the household that has Health Insurance

	Name of Household Member with Health Insurance	Yes/No
Medicaid
Medicare
Tribal (IHS)
Private Pay
UPHP
VA Health

Please fill out for each person in the household that has a disability

	Name of Household Member with disability
Mental Health
Developmental
Physical
Chronic Health

Utility Providers

	Name of Provider	Account Number
Electric Provider
Heating Provider

Please upload the following documents:
1. Picture ID's for all adults in the household (front and back)
2. ALL household income for the last three (3) months
3. Social Security Benefit Statement (if applicable)
4. Trailer Title or Property Deed
5. Self- Declaration of no income(needs to be notarized) if No income in household
All these items can be uploaded or emailed to kkrull@clmcaa.com

Application can not be processed until all these documentations are received
Upload documents here.

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*Once a completed application is turned in, staff will have 10 days to review the application.*
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