HWAP Intake Form
Are you a...
Homeowner
Renter
Housing Provider / Property Manager
Do you reside in the following zip codes: 43201, 43202, 43204, 43205, 43210, 43211, 43212, 43214, 43215, 43216, 43218, 43219, 43220, 43222, 43224, 43226, 43227, 43228, 43231, 43234, 43235, 43236, 43251, 43260, 43265,43266, 43268, 43270, 43271, 43272, 43279,43287, 43291, 43299, 43065?
Yes
No
Is your property in American Addition, Americrest, or Census Tract 7.30? (See above image)
Yes
No
How many people live in your household?
1
2
3
4
5
6
7
8
Other
Is your annual household income under $30,120?
Yes
No
Is your annual household income under $40,880?
Yes
No
Is your annual household income under $51,640?
Yes
No
Is your annual household income under $62,400?
Yes
No
Is your annual household income under $73,160?
Yes
No
Is your annual household income under $83,920?
Yes
No
Is your annual household income under $94,680?
Yes
No
Is your annual household income under $105,440?
Yes
No
How many people live in your household?
1
2
3
4
5
6
7
8
Other
Is your annual household income under $45,180?
Yes
No
Is your annual household income under $61,320?
Yes
No
Is your annual household income under $77,460?
Yes
No
Is your annual household income under $93,600?
Yes
No
Is your annual household income under $109,740?
Yes
No
Is your annual household income under $125,880?
Yes
No
Is your annual household income under $142,020?
Yes
No
Is your annual household income under $158,160?
Yes
No
Have you ever been on the Home Energy Assistance Program (HEAP) or Percentage of Income Payment Plan (PIPP) within the past year?
Yes
No
Not Sure
How did you hear about the Weatherization Assistance Program
Radio
Digital Kiosk
Mailing
IMPACT Program
Referral from family/friend
Community Break
Other
Please upload your:
Universal Application
Proof of Household Income (90 Days)
Citizenship (Birth Certificate, Social Security #, Passport, Voter Registration)
Gas/Electric Bill (90 Days Proof)
File Upload
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Contact Us
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
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