AFH Energize Application

King County Energize: Adult Family Home Application

King County's Energize Program can help with low or no-cost energy saving upgrades for qualifying Adult Family Homes.
Contact Info
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Zip Code*
Do you own or rent the property?*

OwnRent
Do you co-own the AFH with another person?*

YesNo
Co-owner Name

First NameLast Name
Co-owner Email
example@example.com
Co-owner Phone Number
Please enter a valid phone number.
Landlord Name

First NameLast Name
Landlord Email
example@example.com
Landlord Phone Number
Please enter a valid phone number.

Adult Family Home Info
Adult Family Home Name*
Washington State Adult Family Home License Number*
What type of Adult Family Home do you operate?*

Elderly CareMemory CareDisability Services
Do you operate any other Adult Family Homes?*

YesNo
How many Adult Family Homes do you operate?
If you wish to apply for two or more Adult Family Home facilities, please submit a separate Energize application for each facility.
How many residents does this Adult Family Home serve?*
If you wish to apply for two or more Adult Family Home facilities, please submit a separate Energize application for each facility.
How many residents in this Adult Family Home are funded by Medicaid?*

Would you be interested in having a King County Health and Environmental Investigator (HEI) visit your home to conduct a free indoor air quality assessment and provide a free BlueAir 211i Max HEPA air filter?*

Yes, please contact me to schedule an assessmentNo, thank you
HEPA Filter Information: BlueAir 211i Max HEPA air filter

Client Release Form
Property Address: {address}

If you are eligible to receive King County home improvement services, the work will be performed by a qualified approved licensed contractor. The contractor will obtain a mechanical permit from King County, and the installation will be inspected by the King County Permitting Division once complete.
Owner and/or Resident Acknowledgement

Indemnification: I hereby release and pledge to hold harmless, indemnify and defend King County, it’s agents, elected and appointed officials, servants and employees (collectively, “Indemnified Parties”), harmless from and against any liability and all claims for injuries, sickness or damage to persons or property of whatsoever kind or character in connection with the work, or any act or eventuality arising from this work, performed by any of the Indemnified Parties and any business contracted by any of the Indemnified Parties to perform work in the home located at the address listed above.

Attest by signing below, I agree to provide access to my home (address listed above) by the King County Energize program contractors and their crew members for purposes of site evaluation, testing, installing a heating system, improvements listed on work orders, and follow-up inspection(s). I hereby release and hold harmless King County, and it’s employees, from any liability in connection with the work.
Signature*

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Disclaimer Form
Public Records Disclaimer

I acknowledge that this application, and all information contained herein, is a public record and may be subject to disclosure.

Interpretation Service Disclaimer

Interpretation service provided in support of the King County Energize! heat pump program is intended as a supporting service. Interpreters will attempt to provide accurate interpretation. Interpretation services do not, and are not intended to, constitute legal advice. King County, its officers, employees, and/or agents shall not be liable for damages or losses of any kind arising out of, or in connection with, the use of interpretation services.
Signature (Must be the home occupant or an authorized representative of the home occupant) I understand the Public Record and Interpretation Services Disclaimers stated above.*

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King County Energize: Adult Family Home Application