Households Registration Form

Households Application
Personal Information
Full Name (or Business Name)*
Birth Date*

MonthDayYear
Contact Information
Email Address*
example@example.com
Mobile Number*
Home/Business Number
Preferred Method of Contact*
(Email/Phone)
Address Requesting HEAR Program Qualifying Items*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Service/Equipment Information

(Eligible Equipment Only)
Upgrade type: Appliances

Eligible Equipment INCLUDE:
- Electric Heat Pump Water Heater
- Electric Air SOURCE or Ground source Heat Pump for SPACE Conditioning
- Commercial or Residential Induction Kitchen Equipment
- Electric Heat Pump CLOTHES Dryer
Upgrade Type: Electric Service necessary for the installation of high efficiency electric equipment

Eligible Equipment INCLUDE:
- Electrical SERVICE and Panel Upgrade
- Electric Wiring
Service/Equipment Needed
Eligible Equipment purchased (If applicable)
Property/Housing Information
Property/Housing Type
(Examples Include Mobile homes, Multifamily Home, Single family Home, Apartments, commercial buildings, etc.)
Please review eligible equipment and Income limitations before filling out.

Household Information

(If applying as a Landlord leave this page blank)
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By signing I acknowledge that all the information on this form is true and correct to the best of my knowledge. I understand that service is not guaranteed and is dependent on funding and eligible repairs listed in the funder guidelines.
Date

MonthDayYear
Date
Head of Household Name

First NameLast Name
Head of Household Signature

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**Copies of Photo ID for every person of the age 18 years or older living in the home is required** Eligible Photo ID’s include Drivers License, State ID, and Passports.

**Copies of Income for every person living in the home is required** Examples of income documentation includes but are not limited to Pension, 3 months paystubs, or if self-employed 2 years tax returns, child support, TANF. **Additional documentation may need to be provided. DO NOT PROVIDE ORIGINAL DOCUMENTS, WE ASK FOR JUST COPIES**

Return all documents requested in enclosed envelope at 13120 W 13th Ave Ste 2, Airway Heights, WA 99001 OR send via email to rebate@cawh.org

For any questions call (509) 437-0760 or email rebate@cawh.org
Photo ID

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Photo ID

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Photo ID

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Photo ID

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Photo ID

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Income Documentation

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Income Documentation

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Income Documentation

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Income Documentation

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Income Documentation

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FILL OUT EVERY PERSON, INCUDING YOURSELF, THAT LIVES AT THE ADDRESS, WHETHER THEY CONTRIBUTE OR NOT. **IF ANY REQUIRED DOCUMENTS ARE OMITTED OR THE FORM IS NOT COMPLETE YOUR REQUEST WILL BE DENIED WITH NO NOTICE SENT**

If additional space is needed for household members, please fill out the table on another copy of the form.

Landlord Information

(As the Landlord, you must fill out and sign the Property Owner agreement)
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By signing I acknowledge that all the information on this form is true and correct to the best of my knowledge. I understand that service is not guaranteed and is dependent on funding and eligible repairs listed in the funder guidelines.
Date

MonthDayYear
Date
Landlords Signature

First NameLast Name
Landlords Signature

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**Copies of Photo ID for every person of the age 18 years or older living in the home is required** Eligible Photo ID’s include Drivers License, State ID, and Passports.

**Copies of Income for every person living in the home is required** Examples of income documentation includes but are not limited to Pension, 3 months paystubs, or if self-employed 2 years tax returns, child support, TANF. **Additional documentation may need to be provided. DO NOT PROVIDE ORIGINAL DOCUMENTS, WE ASK FOR JUST COPIES**

Return all documents requested in enclosed envelope at 13120 W 13th Ave Ste 2, Airway Heights, WA 99001 OR send via email to rebate@cawh.org

For any questions call (509) 437-0760 or email rebate@cawh.org
Photo ID

Cancelof
Photo ID

Cancelof
Photo ID

Cancelof
Photo ID

Cancelof
Photo ID

Cancelof
Income Documentation

Cancelof
Income Documentation

Cancelof
Income Documentation

Cancelof
Income Documentation

Cancelof
Income Documentation

Cancelof
FILL OUT EVERY PERSON THAT LIVES AT THE ADDRESS. IF ANY REQUIRED DOCUMENTS ARE OMITTED OR THE FORM IS NOT COMPLETE YOUR REQUEST WILL BE DENIED WITH NO NOTICE SENT**

If additional space is needed for household members, please fill out the table on another copy of the form.

Property Owner Agreement
I the Owner agree to:
- Not evict the tenant based upon the energy improvements.
- To not increase the rent of any tenant in the building as a result of the energy improvements, (rent increases to recover actual increases in property taxes, specified operating expenses or property improvements outside the scope of the rebate project)
- If the property is sold within a specified time of receipt of the rebates, the above conditions apply to the new owner and must be included as a clause of the purchase agreement.
By providing my signature I agree with the parameters set above and understand that corrective action will be taken if the owner fails to abide by any agreements.
Date

MonthDayYear
Date
Owners Signature

First NameLast Name
Owners Signature

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Eligible High Efficiency Electric Equipment
Upgrade type: Appliances

Eligible Equipment include:
- Electric Heat Pump Water Heater
- Electric Air Source or Ground source Heat Pump for space Conditioning
- Commercial or Residential Induction Kitchen Equipment
- Electric Heat Pump clothes Dryer
Upgrade Type: Electric Service necessary for the installation of high efficiency electric equipment

Eligible Equipment include:
- Electrical service and Panel Upgrade
- Electric Wiring
Vendor Payments:
- The City of Airway Heights has confirmed they will pay vendors directly for large purchases.
- For items that do not require installation and can be purchased with an eligible vendor, the City will reimburse clients. However, reimbursement will only be provided upon submission of a valid receipt as proof of purchase.
**APPLIANCES MUST BE COVERED UNDER THE ELIGIBLE HIGH EFFICIENCY ELECTRIC EQUIPMENT REQUIREMENTS IN ORDER TO GET A REIMBURSEMENT**
Should be Empty:

Households Application

Personal Information

Contact Information

Service/Equipment Information

Property/Housing Information

Household Information

Landlord Information

Property Owner Agreement

Eligible High Efficiency Electric Equipment