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Programa Nuestro Hogar Application
Name
First Name
Last Name
Alternative Name
First and Last
Home Address
Please include zipcode
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
*
example@example.com
Are you a NW Natural customer?
*
Please Select
Yes
No
Not sure
NW Natural Account Number
*
What year is your home built in?
*
How long have you been living in your house for?
*
Do you identify as Hispanic and/or Latino
*
Please Select
Yes
No
Prefer not to answer
Is your home heated by gas?
*
Please Select
Yes, my home is heated by a gas furnace
No, I have electric heating
I am not sure
Do you prefer speaking in Spanish or English?
*
Please Select
Spanish
English
Both (Spanglish)
Other
How many permanent residents live in your household?
*
What is your Gross Annual Household Income?
*
Please Select
Less than $25,000
$25,000 - $34,999
$35,000 - $49,999
$50,000 - $74,999
$80,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 or more
Dont Know
Prefer not to answer
Best way to communicate with you
*
Phone Call
Text
Email
Are you a homeowner / renter
*
Home-Owner
Renter
Have you previously applied for any type of assistance or subsidy for home improvements
*
YES
NO
How did you hear about our program?( Include Person Name)
*
Person of Referal / Company of Referal / Friends Name / Person Name
What support is available for families facing unemployment or living with a disability, and how can they access resources to meet their basic needs??
Do you have any other comments or questions for us?
NW Natural Bill Picture
*
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