Weatherization Services Application

Chippewa Luce Mackinac Community Action Agency Weatherization / E- Services Application
What are you applying for?

WeatherizationWater/SewerHeatMetered Plumbing Repair
DATE

MonthDayYear
Date
NAME
Is there a Veteran in the household?

YesNo
If yes, who?
Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary/Emergency Phone Number:
EMERGENCY CONTACTS NAME
Email Address
example@example.com
Do you rent or own your home?

RentOwn
Landlord name and contact information
HOH Name

First NameLast Name
Social Security Number
Race/Ethnicity
Age
DOB

MonthDayYear
Date
Gender
Name

First NameLast Name
Relation to HOH
Social Security Number
Race & Ethnicity
Age
DOB
Gender
Name

First NameLast Name
Relation to HOH
Social Security Number
Race & Ethnicity
Age
DOB
Gender
Name

First NameLast Name
Relation to HOH
Social Security Number
Race & Ethnicity
Age
DOB
Gender
Name

First NameLast Name
Relationship to HOH
SSN
Race & Ethnicity
Age
DOB
Gender
Name

First NameLast Name
Relationship to HOH
Social Security Number
Race & Ethnicity
Age
DOB
Gender
Name

First NameLast Name
Relation to HOH
Social Security Number
Race & Ethnicity
Age
DOB
Gender
Name

First NameLast Name
Relationship to HOH
Social Security Number
Race & Ethnicity
Age
DOB
Gender
Does the household have income?

YesNo
Total Monthly Income
SSI
Monthly Amount
Name of household member with income
SSDI
Monthly Amount
Name of household member with income
SSA (Retirement SS) Yes/No
Monthly Income
Name of household member with income
Earned Income/Wages Yes/No
Monthly Amount
Name of household member with income
Child Support Yes/No
Monthly Income
Name of household member with income
Cash Assistance (MDHHS) Yes/No
Monthly Income
Name of household member with income
General Assistance (Tribal) Yes/No
Monthly Amount
Name of household member with income
VA Disability/Income Yes/No
Monthly Amount
Name of household member with income
Does the household have health insurance?

YesNo
Medicaid Yes/No
Name of household member with insurance
Medicare Yes/No
Name of household member with insurance
Tribal Health Center Yes/No
Name of household member with insurance
Private Pay Yes/No
Name of household member with insurance
UPHP Yes/No
Name of household member with insurance
VA Health Yes/No
Name of household member with insurance
Does anyone in the household have a disability?

YesNo
Name of the household member(s) a mental disability
Name of the household member(s) a developmental disability
Name of the household member(s) a physical health disability
Name of the household member(s) a chronic health disability
Electric Provider
Account Number
Heating Provider
Account Number
Water Provider
Account Number
Please Upload the Following Documents:

1. Picture IDs for all adults in the household

2. ALL household income for the last 90 days for Weatherization and for all other programs, 30 days of income.

3. Benefit statement (Food Assistance, Child support, etc

4. Trailer title (If Applicable) or homeownership deed.

By signing below, you agree that all information listed is true to your best knowledge. You also consent to information collection that is pertinent to Weatherization.
Take Photo
Upload Documents

Cancelof
Signature

Clear
DATE

MonthDayYear
Date
*Once a COMPLETED application is turned in, staff have 10 days to review the application. *
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