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  • Energize Duvall: Single Family Homeowner or Renter Application

  • Instructions and Notes

    King County’s Energize program installs heat pumps and other home efficiency upgrades in low- and moderate- income homes in King County.

    The Energize Duvall pilot program is now open to eligible applicants.

    Program Eligibility

    • Must be a Duvall-area resident within specific neighborhoods of zip codes 98014 or 98019.
    • Your current primary heating system must be natural gas. This includes natural gas forced-air furnaces, wall heaters, and boilers.
    • Your household income must be less than 80% of Area Median Income to qualify for 100% cost coverage.
    • Energize is open to both homeowners and renters of single-family homes.

    If approved for Energize, King County will cover 100% of installation costs of the heat pump system. In addition to heat pump upgrades, homes may be eligible for other building upgrades such as insulation, weatherization, ventilation, and home appliances. 


    King County reserves the right to decide which participants to move forward with based on alignment with County and grant funding goals. 


    If you would like to request assistance completing this application in another language, or if you are unable to fill out this application electronically, please email energize@kingcounty.gov or call 206-263-3003.  

     

    Please submit your application using the form below. If you have any questions or would like to submit a paper version of this application, please contact energize@kingcounty.gov.

     

    * Indicates required questions.

  • Contact Info

  • Format: (000) 000-0000.

  • Household Info

  • Which language is spoken in your home most often?*
  • Will you require language assistance when interacting with Energize program staff and contractors? *
  • Are you or anyone in your household currently expecting a child under age 5 due to pregnancy or approved (or pending) foster placement or adoption process?*
  • Do you or does a member of your household have asthma, COPD (Chronic obstructive pulmonary disease), or require the use of supplemental oxygen?*
  • How long have you lived at this address?*
  • Do you own or rent the home?*
  • Do you co-own the home with another person?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • How did you hear about Energize?*

  • Income Self-Attestation Form

    Please complete this to the best of your ability.

  • Definitions

    Adult: any person 18 years or older.


    Household: all persons in your household (inclulding children), living at the same address. A household may be a family, two or more families living together, or any other group of related or unrelated persons sharing living arrangements.


    Income: the total annual income before taxes of all family and non-family members 18+ living within the household. It includes all gross wages, tips, rental income, public assistance, social security or pensions, income from self-employment, alimony, interest, unemployment benefits, public assistance or any other sources of income defined by the IRS income tax return for the previous tax year.


    Determining My Household’s Annual Income

    A good way to determine your household’s annual income is by looking at last year’s tax returns.

    • If the only adults in your household are you and your partner or spouse, a jointly filed tax return for the previous year would provide your household income.
    • If you filed separate tax returns than your partner or spouse, or you have multiple adults in your household that filed separately, you would combine the incomes of each separate tax return.


    If your household income changes prior to heat pump installation, such that your household no longer qualifies for the heat pump program, it is expected you will notify your Energize case manager or an Energize program manager.

    Please review the following Annual Income Limit Chart:

    Household Size Full Cost Coverage Income Limit Partial Cost Coverage Income Limit
    1 $84,850 $127,275
    2 $96,950 $145,425
    3 $109,050 $163,575
    4 $121,150 $181,725
    5 $130,850 $196,275
    6 $140,550 $210,825
    7 $150,250 $225,375
    8 $159,950 $239,925

    Income Information

    I am aware of the two options available through King County for participating in the Energize program.

    1. Full cost coverage for applicants whose household income is below the limit listed in the Full Cost Coverage Income Limit Chart, King County will cover 100% of installation costs.
    2. Partial cost coverage for applicants whose household income is below the limit listed in the Partial Cost Coverage Income Limit Chart, Energize will cover 80% of installation costs, while the applicant is responsible for the remaining 20% of installation costs. 

    Please note that King County may require documentation of your household's annual income in order to qualify for Energize. One of the following documents can be used to qualify for Energize. You have the opportunity to upload a digital copy of one the following below. 

    • IRS 1040 for most recent tax year
    • Past three months' of paystubs
    • Seattle City Light Utility Discount Program - Utility bill stating enrollment
    • Medical (Apple Health-Medicaid) - ProviderOne Number with Health Care Authority or DSHS
    • Basic Food (also known as SNAP) - ACES ID number
    • Cash Assistance (DSHS) - ACES ID number
    • ORCA Lift - ORCA Lift ID number on the back of your card
    • Social Security Benefits - Copy of your award letter
    • Veterans - Since it’s a federal program, we’d need a copy of your award letter
    • ABD (Aged Blind Disabled) - ProviderOne Number with DSHS
    • SSI (Supplemental Security Income) - ProviderOne Number with Health Care Authority
  • Please select:*

  • Full Cost Coverage Self-Attestation

    By signing below, I certify that I qualify for full cost coverage in King County’s Energize Program because my total household income does not exceed the maximum income for my household size, as indicated in the Annual Full Cost Coverage Income Limit Chart. I acknowledge that King County may share this application, including income information, with its contractors and program partners. 


    I also acknowledge that if my income exceeds the income limit listed in the Annual Full Cost Coverage Income Limit Chart, then I will be required to pay a share of the project cost. 


    I certify that the information I am providing is true and accurate. I further understand that providing misleading information about my household income constitutes an act of fraud and may render me ineligible to participate in the King County Energize Program. If King County finds that I have provided false information about my income or other eligibility criteria, I may be required to repay any incentives or cost-shares provided by the King County. King County reserves the right to request additional proof of income to verify income qualification. 

  • Partial Cost Coverage Self-Attestation

    By signing below, I certify that I qualify for partial cost coverage in King County’s Energize Heat Pump Installation program because my total household income does not exceed the maximum income for my household size, as indicated in the Partial Cost Coverage Annual Income Limit Chart. I acknowledge that King County may share this application, including income information, with its contractors and program partners. 


    I also acknowledge that, if selected for heat pump installation under this program, I will be expected to pay twenty percent (20%) of the full installation costs, including costs for equipment, labor, and taxes. I also acknowledge that I will be required to pay this amount prior to heat pump installation, or sign a payment plan with my installer to ensure this requirement is met. King County will pay the remaining eighty percent (80%) of the heat pump cost.  


    I certify that the information I am providing is true and accurate. I further understand that providing misleading information about my household income constitutes an act of fraud and may render me ineligible to participate in the King County Energize Program. If King County finds that I have provided false information about my income or other eligibility criteria, I may be required to repay any incentives or cost-shares provided by the King County. King County reserves the right to request additional proof of income to verify income qualification. 

  • Signing Date
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  • Building Information

  • Heating, Ventilation, & Air Conditioning (HVAC) Questions

  • What is the main type of fuel used to provide heat in your home?*
  • What is the main type of heating system your home uses for heating?*
  • How old is your home's heating system? Please answer for your primary heating system.*
  • Is your primary heating system functional? Please answer for your primary heating system.*
  • Does your home have Air Conditioning (A/C)?*

  • Other Home Appliances

  • What type of water heater do you use in your home?*
  • Which of the following items does your building currently have? (Select all that apply)

  • Utility Information

  • Are you currently enrolled in Seattle City Light's Utility Discount Program?*
  • Are you currently enrolled in Puget Sound Energy's Bill Discount Rate Program?*
  • Date Signed
     - -

  • Demographics

  • These last set of questions will ask for information about you and those living in your household. These questions are optional and will only be used to ensure the Energize program is reaching all communities in King County.

  • Please choose one or more races that you consider yourself to be. (Select all that apply)
  • Please choose one or more races of persons present in your household. (Select all that apply)
  • Which gender do you consider yourself to be? (Select all that apply)
  • Do you or do any members of your household identify as a member of the LGBTQIA+ community?
  • Do you or a member of your household experience any of the following? (Select all that apply)
  • Which of the following best describes your household or caregiving responsibilities? (Select all that apply)

  • 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 all necessary permits required by the local permitting authority, and the installation will be inspected by the state or local permitting agency once complete.

  • Owner and/or Resident Acknowledgement

    Indemnification: I hereby release and pledge to hold harmless, indemnify and defend King County, its agents, elected and appointed officials, servants and employees, in addition to Energize Program funders including Puget Sound Energy, and other current or future funders, and their agents, officials, 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 its employees, from any liability in connection with the work. 

  • Date Signed
     - -

  • 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. 


    Data Access & Sharing Disclaimer 


    I acknowledge that if approved for installations, I will be required to provide King County and PSE, upon request, access, inspection, and account/consumption data for evaluation and quality assurance purposes. I will also authorize King County to share utility data with program contractors and consultants for installation, energy efficiency verification, and greenhouse gas reporting.
     
    Interpretation Service Disclaimer 


    Interpretation service provided in support of the King County Energize 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.

     

     

  • Date Signed
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  • Application Attestation

  • Attestation

    I attest that the answers provided in this application are true and accurate to the best of my knowledge.

  • Date
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  • Should be Empty: