CAFI Weatherization

INSTRUCTIONS FOR APPLYING FOR WEATHERIZATION
To apply for weatherization services, it is important that you provide all the information requested. Before we can assist you with energy related repairs to your residence, the need steps must be

STEP 1: READ THROUGH THIS ENTIRE PACKET OF INFORMATION

STEP 2: COMPILE THE FOLLOWING DOCUMENTS Completed and signed Program application (2 pages) completed and signed. Georgia Weatherization Assistance Program-Application Weatherization Authorization Form

Authorization to Release of Information

Copy of Social Security Card for every household member. Copy of Driver's License/State ID for every member (household members 16 years or older) Proof of income for every member of the household (Must show most recent income for 1 month) Proof of Home Ownership (recent property tax records or recent mortgage statement) Recent copy of Utility bill & gas bill (utility bill must show your annual usage)

STEP 3: Bring or mail all documents above to the CAFI office for intake and processing: County of Residence: Carroll, Coweta, Troup, Meriwether, Heard, Douglas, Harris, Muscogee

Return via mail to: CAFI Weatherization

1380 Lafayette Parkway Lagrange, Ga 30241
Note: If you are employed, we will need copies of your four most recent check stubs. If you receive SSI, Retirement Check, pension, and or Social Security, we will need a copy of your current year reward letter or a recent bank statement. If there is no income in the household, please complete the zero-income form. Failure to provide required documents may result in delay or denial of your application.
PROGRAM APPLICATION
Your Social Security Number*
First Name*
M.I.
Last Name*
Date of Birth (MM-DD-YYYY)*
Address*
City*
State*
Zip Code*
Home Phone
Other Phone (if different from Home Phone)*
Number of people living in Household?*
How many people living in the household Disabled?
Briefly explain
Please add household members below
Name
Relationship
DOB
Income
Marital Status
Race
Name
Relationship
DOB
Income
Marital Status
Race
Name
Relationship
DOB
Income
Marital Status
Race
Name
Relationship
DOB
Income
Marital Status
Race
Demographic
Marital Status*
Race*
Education*
Primary Language spoken in home*
HOUSING & ENERGY
Do you live in a mobile home?*
Do you rent or own your home?*
How do you heat your home?

PropaneNatural GasElectricWood
Has your home been weatherization by us before?*
If so, when was the work done?
Financial
Employment Status*
If employed, please list the name of the company and address
Total monthly income*
Where does your income come from?*

Social SecuritySSIWagesGeneral Assistance (GA)Other
Are you related to anyone employed by CAFI?

YesNo
Georgia Weatherization Assistance Program - Application Form
Income Information - (Check all that apply) Source(s) of Income:*

Supplemental Security Income (SSI)TANFWagesNo IncomeSelf-EmploymentSocial SecurityRailroad RetirementPensionVA BenefitsUnemploymentPublic AssistanceOther
Household Demographics (Duplicated Count):
Number of Elderly > 60 years of age*
Number of Children < 2 years of age*
Number of Children 3-5 years of age*
Number of Children 6-17 years of age*
Applicant's Gender*
Number of Native Americans:
Number of Disabled:
Number of Seasonal/Farm Workers:
Total Number in Household:*
Total Number of Elderly, Disabled or Young Children ( Unduplicated Count):*
Home Energy Assistance through LIHEAP received? (yes/no)
At-Risk Occupants:
Georgia Weatherization Assistance Program - Application Form
Number of Elderly Persons (65 years or older)
Number of Infants (2 years or less)
Number of Person(s) Pregnant*
Number of Persons with Health Condition(s) Exasperated by High/Low Temperature Conditions
Explain Health Condition(s)
Dwelling Demographics
Dwelling Demographics

Site BuiltManufactured/Mobile HomeMulti Family
Primary Heating Fuel

Natural GasOilLiquid Propane GasElectricityWoodKeroseneOther
Air Conditioning:

Window UnitsCentral ACPortable
Roof Condition
Specific Issues
Owned: (yes/no)*
Rented: (yes/no)*
Other: (specify)
Is your residence currently For Sale, in Foreclosure or in the process of being Foreclosed? (yes/no)*
Landlord Information
Name
Address

Address

Street Address Line 2

CityState

Zip Code
City
Phone
I declare to the best of my knowledge the above information is accurate and is a true statement of my total household income:
Applicant Signature

Clear
I,
Name of Applicant
have applied for weatherization assistance with
Weatherizing Agency
on

MonthDayYear
Date
I fully understand that this authorization form is a part of the intake process and shall be completed before any weatherization work can be performed.
For Owner Occupied Dwellings:
Homeowner/ Authorized Agent Certification
I,
Owner/Authorized Agent
, certify that I am the owner of the dwelling unit located at
Address
I do hereby authorize
Weatherizing Agency
to make energy-related repairs* and release
Weatherizing Agency
from all liability whatsoever in the performance of this Authorization as long as the work has been completed in a workmanlike manner.
Agency Representative Signature

Clear
Owner Signature

Clear
Date

MonthDayYear
Date
For Renter Occupied Dwellings:
I,
Owner/Authorized Agent
, certify that I am the owner of the dwelling unit located at
Address
I do hereby authorize
Weatherizing Agency
to make energy-related repairs* and release
Weatherizing Agency
from all liability whatsoever in the performance of this Authorization as long as the work has been completed in a workmanlike manner. I fully agree that following the completion of repairs the rent shall not be raised for a period of two years because of the increased value of the dwelling unit due solely to weatherization assistance and understand that no undue or excessive enhancement shall occur to the value of the dwelling unit.
Agency Representative Signature * particulars may be attached

Clear
Owner/Authorizing Agent Signature

Clear
Fuel Information Release:
I,
Address
hereby authorize
Weatherizing Agency
to release information on my fuel records and data both past and future to if requested. I understand that this information will be used only to provide data for the above named agency, and no information obtained through this release shall be made public in such a manner that the dwelling or occupants can be identified.
Fuel Supplier
Applicant's Signature

Clear
Address
Signature

Clear
Date

MonthDayYear
Date
I, ACTION FOR IMPROVEMENT, INC. MAY OCCASIONALLY NEED TO DISCUSS CERTAIN FACTS REGARDING

MY SITUATION WITH OTHER AGENCIES IN ORDER TO ASSIST ME.

BY SIGNING THIS RELEASE AUTHORIZATION, I HEREBY AGREE TO ALLOW COMMUNITY ACTION FOR IMPROVEMENT, INC. TO RECEIVE INFORMATION FROM OTHER AGENCIES AND TO RELEASE

INFORMATION TO OTHER AGENCIES PERTAINING TO MY CASE.

COMMUNITY ACTION FOR IMPROVEMENT, INC. AGREES AND HAS STATED THAT ALL INFORMATION

RECEIVED OR RELEASED WILL BE NECESSARY FOR PROPER IMPLEMENTATION.

CAFI HEREBY AGREES TO MAINTAIN STRICT CONFIDENTIALITY IN THE HANDLING OF THE CLIENTS INFORMATION IN ACCORDANCE WITH PROGRAMMATIC RULES AND REGULATIONS.
AUTHORIZATION FOR RELEASE OF INFORMATION
UNDERSTAND THAT THE STAFF OF COMMUNITY
CLIENT
DATE

MonthDayYear
Date
WITNESS
DATE

MonthDayYear
Date
Should be Empty:

INSTRUCTIONS FOR APPLYING FOR WEATHERIZATION

PROGRAM APPLICATION

Demographic

HOUSING & ENERGY

Financial

AUTHORIZATION FOR RELEASE OF INFORMATION

UNDERSTAND THAT THE STAFF OF COMMUNITY