Energy Savings Program

Home Energy Assessment Interest Form
PARA ESPAÑOL PRECIONE LA BANDERA DE LA PARTE SUPERIOR DERECHA Y ESCOGER IDIOMA
First Name and Last Name*
Address*

Street Address

CityState

Zip Code
Residential Owner
Are you the homeowner or renter? ( Select all that Apply ) *

Home ownerRenterOther
Home owner Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Renter / Alternative Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
E-mail*
If you do not have one, enter a@a.com
Best way to communicate with you*

EmailTextPhone
Is it a manufactured home or a detached home?*

ManufacturedSingle - Family DetachedDuplex, triplex, quadruplexTownhomeOther
How many people live in the household? *
Type of heat for the home ( Select all that Apply ) *

ElectricGasOther
Do you have air-conditioning?*

YesNo
Select the following utility providers that service your home. (Select all that apply)*

Portland General ElectricPacific PowerCascade Natural GasNW Natural GasAvistaOther
If you have NW Natural gas what is your account number?
Name of the contractor who assisted you:
Name of person of who assisted you
Do you have concerns about your home insulation*

YesNoOther
If YES what concerns do you have, please explain
In what year was the home built? *
Do you have Solar panels ?*

YesNo
Have you previously applied for the Energy Trust of Oregon*

YesNo
Do you have any issues with humidity or mold in the house?*

YesNo
What is your monthly utility bill?*
Have you previously applied for any type of assistance or subsidy for home improvements?*

YesNo
How many hours a day do you use heating during the winter?*
How many hours a day do you use air conditioning during the summer? *
Do you identify as Hispanic and/or Latino? *
Do you prefer speaking in Spanish or English?*
What is your Gross Annual Household Income? *
How did you hear about our program?
Name of Friend or Relative Name
Do you have any other comments or questions for us?
Should be Empty:

Home Energy Assessment Interest Form

PARA ESPAÑOL PRECIONE LA BANDERA DE LA PARTE SUPERIOR DERECHA Y ESCOGER IDIOMA