Northeast Nebraska Community Action Partnership
Weatherization Assistance Program Client Application Form
Please note that the following information is voluntary and will be held in confidence, to be used by the Weatherization Assistance Program. Withholding or falsifying information could lead to disqualification of this application.
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number in Household
*
Household Information:
List all occupants including yourself
Household
*
Household income is received from :
*
Employment
Social Security
Retirement (all types)
Disability
Workers Comp
Net Rental Income
Net gambling or lottery winnings
Unemployement
Self-employed
Other
Public Assistance Information
Check all forms of assistance that your household receives currently and include proof with your application.
*
Supplemental Security Income (SSI)
Aid to Dependent Children (ADC)
Low Income Energy Assistance (LIHEAP)
My Household does not current receive SSI, ADC, or LIHEAP
SSI File Upload
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of
Aid to Dependent Children file Upload
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of
Low Income Energy Assistance file Upload
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of
House Information
I/we
*
Own
Rent the home
Check the box that most accurately describes your home:
*
House
Modular
Mobile
Apartment/Duplex
How long have you lived in your home:
*
Less than 6 Months
Less than 1 year
More than 1 year
5+ years
Type(s) of heating fuel used in your home:
*
Natural Gas
Electric
Propane
Other
I hereby State the Following:
I do, indeed, live at the above address and intend to continue living at that address for a minimum of one year after the weatherization work is complete. I give permission to the NENCAP Weatherization program to weatherize my home. My home is not in the state of remodel, nor do I plan to remodel prior to the completion of the weatherization work. I agree to allow NENCAP and its grantor to determine my eligibility, monitor the progress and completion of the work, and monitor my utility bills before, during, and after completion. I have no legal obligation to NENCAP or its contractors for payment of any part of the work as ordered by the weatherization program. I will not hold NENCAP liable or responsible for unintentional damages by NENCAP staff or contractors.
I understand to weatherize a dwelling unit which is designated for acquisition or clearance by a Federal, State, or Local Program within 12 months from the date weatheriziation of the dwelling would be scheduled to be completed is not allowed under Federal Regulations 10 CFR 440.18(f)(1).
*
Yes
No
Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: