hereby certify that I am the owner/authorized agent, herein referred to as “owner” for the property listed above referred to as “owner” for the property listed above

I hereby give permission to allow Northeast Nebraska CommunityActionPartnership (hereafter known

as the “Agency”) to perform weatherization services according to the U.S. Department of Energy regulations and in conjunction with the current Nebraska state weatherizationplan.

I also agree to the following provisions:

1.I will NOT increase the rent as a result of the improvements made by the weatherization of thehome.

2.I will NOT evict or remove the tenant from the dwelling for a period of one (1) year after the final approved inspection of the property, so as long as he/she complies with all ongoing obligations and responsibilities owed to thelandlord.

3.I(Owner)have nointentionandknowledgeofFederal,State,orLocalProgramsdesignationofmyhomefor acquisition orclearance.

years/months and to the best of my knowledge the unit has not

been weatherized for a previous tenant.

5. I will allow agency, state, or federal officials to inspect the rental property listed above.

6. I agree to allow my home to be photographed for pre-weatherization and post-weatherization documentation.

7. I will agree to any procedures necessary to insulate the sidewalls.

8. The property legal description or mobile home serial number of the rental property is:

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 weatherization of the dwelling would be scheduled to be completed is not allowed under Federal Regulations 10 CFR 440.18(f)(1)

I furthermore do hereby give permission for the property to be weatherized according to the Department of Energy (DOE) standards and regulations and for the inspection of the homeand the work performed by the Agency Weatherization Program. As part of this service, all units will receive a heating system efficiency inspection. The weatherization services and the heating system efficiency inspection will be performed at no cost to the owner/landlord or tenant in single unit dwellings. In the case of heating plant repairs, the Agency Weatherization Program share will not exceed $400.00. If the repairs do not exceed $400.00, the Agency Weatherization Program will repair the heating plant. Should the repairs exceed $400.00 the Agency Weatherization Program will contact the owner or authorized agent to have the heating plant replaced. The Agency Weatherization Program will contribute $500.00 toward therequired

replacement, if installed to meet the Nebraska Energy Weatherization Assistance Program

specifications. If deficiencies are found with the water heater, the owner shall repair or replace the water heater. The Weatherization Program may contribute a maximum of $150.00 if Weatherization Program installation requirements are met. The weatherization of the unit will not commence until such time as the furnace and/or water heater have been made safe and operable. Weatherization work on rental units may be a shared responsibility of the owner/landlord and the Agency Weatherization Program. 

Weatherization materials may include, but are not limited to, the following items: insulation, caulking, glazing, weather stripping, doorsweeps, thresholds, primary doors and primary windows, pipe wrap, water heater blankets, venting, minor
repairs, and glass replacement. The decisions concerning material type and quantity shall be the responsibility of the Agency providing the service. The determination for the type of work to be implemented on your home is solely based on the completion of an inspection and energy audit that accesses how much energy can be saved with
implementation and which work provides a costeffective savings-to-investment ratio (SIR).

This material was prepared with the support of the U.S. Department of Energy (DOE), Low Income Weatherization Assistance Program Grant. However, any opinions findings conclusions or recommendations expressed herein are those of the author and do not necessarily reflect the views of DOE.