New Weatherization App

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Main Phone 828-438-6255
Toll Free 866-427-6452
Fax 828-433-5721

Alexander, Burke, Caldwell, Catawba, Gaston,
Mecklenburg, Rutherford, Stanly, Union
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INTRODUCTION & REQUIRED DOCUMENTS

The mission of the North Carolina Weatherization Assistance Program is to improve household energy efficiency and energy related health and safety, for low-income North Carolina residents. The program focuses primarily on serving the elderly, the disabled, families with young children, high-energy users, and the heavily energy burdened. The Heating and Air Repair and Replacement Program focuses specifically on the repair or replacement of unsafe, inoperable, and inadequate heating and cooling systems. Weatherization assistance is available to low income residents living in single-family houses, apartments, condominiums, and mobile homes. You DO NOT have to own a home to be eligible. Renters MUST have written permission from the property owner before services are rendered. Eligibility criteria may vary between programs. Multifamily units cannot exceed 4 connected units and/or 5 buildings total on property. Each unit must be individually metered.

What the Weatherization Assistance Program (WAP) and Heating and Air Repair and Replacement Program (HARRP) do:
- Evaluates homes for energy-related efficiency and safety upgrades
- Insulates attics, floors, and walls as needed
- Makes minor repairs to address energy-related health & safety issues
- Repairs or replaces heating/cooling systems if required
ELIGIBILITY DOCUMENTATION REQUIREMENTS
**Provide ALL that apply to each household member. Provide a copy of awards letter or printout for all that apply**

HOUSEHOLD INCOME DOCUMENTATION

Income is defined as cash receipts earned and/or received before taxes or deductions. Income includes money, wages and salaries before deductions, regular payments from social security, railroad retirement, and unemployment compensation, strike benefits from union funds, worker’s compensation, veteran’s payments, training stipends, alimony and military family allotments. Private pensions, government employee pensions (including military retirement pay), and regular insurance or annuity payments; dividends, interest, bonds, and other investments (including 1401(k), 403(b), SEP, ESOP, net rental; income, net royalties, periodic receipts from estates or trusts and net gambling or lottery winnings.
- Government issued photo identification copy (for all adult occupants)
- Complete Income Tax Returns (including W-2 copies) for all required to file for past year
- Pay check stubs for last 2-months (including YTD pay) and final check stub from each job ended in last 12-months
- Unemployment benefits history for last 12-months
- Proof of Social Security numbers for ALL occupants (i.e., card or printout of number from Social Security office)
- Social Security Administration benefits history (SSA and SSI) for last 12-months (attach Social Security printout)
- Veterans Administration benefits history for last 12-months
- Disability Pension income history for last 12-months
- Retirement, pension, IRA, dividend, or annuity income history for 12-months
- Alimony payment history for last 12-months
- Rental property income history for last 12-months
- Profit & Loss Statements for all self-employed household members for last 2-years (professionally prepared)
- Notarized statement for zero-income
- All other income history for each household member for last 12-months
DWELLING OWNERSHIP DOCUMENTATION
- Parcel Tax Record Card issued by the county tax administration within last 30-days
- Property Tax Notice issued by the county tax administration within last 12-months
- Deed recorded and stamped at the county court house in the county where the dwelling is located
- NC DMV issued motor vehicle Certificate of Title for a mobile home or Bill of Sale (exceptions may apply)
DWELLING FUEL/UTILITY CONSUMPTION HISTORY
- 12 months fuel/energy history for each fuel/utility provider serving the dwelling (must include kilowatt hours; meter reading date, therms/CCF, number of days in the cycle and billing amount). Printout must include account name and account number.

HEATING SYSTEM
Type of Heat *
Gas/Propane Service *
Heat Working *
If no, how long not working?
AIR CONDITIONING SYSTEM
Type of A/C *
A/C Working *
# of window units *
If no, how long not working?
APPLIANCES
Type of Stove *
Type of Dryer *
Type of Water Heater *
Refrigerator Working *
ELECTRICAL
Type of wiring in home *
Do fuses blow out *
Do breakers flip off *
Any fires caused by wiring? *
ROOF
Type of Roofing *
Leaks Present *
How Many Leaks *
Leak Locations
PLUMBING
Indoor Plumbing *
Water Source *
Sewer or Septic *
# of Leaks *
USE THIS TABLE WHEN ESTIMATING WOOD OR KEROSENE COSTS

Applicant used wood or Kerosene and did not use a routine vendor for heating for the past 12 months.
What, if any, issues are you currently having with any of the household systems above? Indicate below.
UTILITY AUTHORIZATION

Enter account information for all utility accounts (i.e., PNG, Duke Energy, etc.). Account numbers are required.
UTILITY COMPANY: *
UTILITY COMPANY:
UTILITY COMPANY:
UTILITY COMPANY:
NAME ON ACCOUNT: *
NAME ON ACCOUNT:
NAME ON ACCOUNT:
NAME ON ACCOUNT:
ACCOUNT NUMBER: *
ACCOUNT NUMBER:
ACCOUNT NUMBER:
ACCOUNT NUMBER:
This application authorizes Blue Ridge Community Action, Inc. (BRCA) to verify utility information PROVIDED BY CLIENT in order to qualify applicant for the program and to verify the reduction of energy usage. The information obtained will be kept confidential.

# of persons in household *
HOUSEHOLD DEMOGRAPHIC INFORMATION

All Occupants MUST be listed & full Social Security number is REQUIRED
Head of Household *
Date of Birth *
Relationship to applicant *
Marital Status *
Social Security # *
Race *
Gender *
Disabled *
Education *
Family Member 1
Name
Date of Birth
Relationship to applicant
Marital Status
Social Security #
Race
Gender
Disabled
Education
Family Member 2
Name
Date of Birth
Relationship to applicant
Marital Status
Social Security #
Race
Gender
Disabled
Education
Family Member 3
Name
Date of Birth
Relationship to applicant
Marital Status
Social Security #
Race
Gender
Disabled
Education
Family Member 4
Name
Date of Birth
Relationship to applicant
Marital Status
Social Security #
Race
Gender
Disabled
Education
Family Member 5
Name
Date of Birth
Relationship to applicant
Marital Status
Social Security #
Race
Gender
Disabled
Education
Family Member 6
Name
Date of Birth
Relationship to applicant
Marital Status
Social Security #
Race
Gender
Disabled
Education
Family Member 7
Name
Date of Birth
Relationship to applicant
Marital Status
Social Security #
Race
Gender
Disabled
Education
Name of Veteran(s) that live in the home

HOUSEHOLD INCOME INFORMATION

ALL income earned by ALL Occupants for the last 12 months MUST be listed. One-time distributions should also be listed below . Be sure to list each source of income for each occupant separately.
Family Member
Source of Income
From Date - To Date
Monthly Amount
Family Member
Source of Income
From Date - To Date
Monthly Amount
Family Member *
Source of Income *
From Date - To Date *
Monthly Amount *
Family Member
Source of Income
From Date - To Date
Monthly Amount
Family Member
Source of Income
From Date - To Date
Monthly Amount
Family Member
Source of Income
From Date - To Date
Monthly Amount
Family Member
Source of Income
From Date - To Date
Monthly Amount
Family Member
Source of Income
From Date - To Date
Monthly Amount
Family Member
Source of Income
From Date - To Date
Monthly Amount
Family Member
Source of Income
From Date - To Date
Monthly Amount
Family Member
Source of Income
From Date - To Date
Monthly Amount
Family Member
Source of Income
From Date - To Date
Monthly Amount
Does anyone in the household receive any of the following sources of income (Supporting Documentation REQUIRED):

Temporary Assistance for Needy Families (TANF) ( Form DSS-8108 Notice of Approval) Supplemental Security Income (Award Letter, Benefits Information Form, Cost of living Adjustment Letter) Crisis Intervention Program (Form DSS-8107 Approval/Denied Notice) Food Stamps (Form DAA-8551 Notice of Approval) Low Income Energy Assistance Program ( Form DSS-8107 Approval/Denial Notice)
If you are declaring zero income you are required to have a notarized Self-Declaration form which can be found bottom of this page.

APPLICATION FOR SERVICES-SUPPLEMENTAL QUESTIONNAIRE
Describe relationship of the applicant to a person affiliated with BRCA (relative's name and relationship to applicant):
Describe prior weatherization services received by applicant (name of provider, date of service, what was done). Indicate what other housing services you have applied for (Urgent repair, Rehab, etc.). Provide name of agency so BRCA can coordinate services:
Describe the circumstance surrounding the dwelling being for sale in the past 12-months, or being subject to foreclosure /condemnation (listing/filing date, actions taken to date by all parties involved, attorney name, etc.):
Describe circumstances requiring utility/fuel bills to be in the name of someone other than the applicant:
List type, size and number of pets living in the home. If pets live outside, are they secured:
List type of pests that are present and how long they've been in the home:
Describe medical status of any household member who: suffers from a chronic health condition, is suffering from a serious illness, is recovering from a major injury, or who is pregnant (member name, type of condition, areas of body affected, duration of injury/illness/condition):
Any other issues in the home that need to be addressed (repairs needed, structural issues, etc.):

PERMISSIONS AND RELEASES
Application is not complete without Uploaded Documents ( Income , Medical, Proof of Ownership. etc)

Upload
pdf, doc, txt, zip, jpg Cancel of
PLEASE READ CAREFULLY

I, as an applicant for Weatherization and HARRP services, herby authorize the verification of all information provided in the application for service. I further understand that re-verification of my eligibility will take place a minimum of once every 12 months. I agree to notify the service provider should any information provided change prior to receipt of services. I understand and agree that pursuant to federal law, identifying information provided by me for determination of household eligibility for Weatherization and/or HARRP assistance will be considered confidential and, unless otherwise authorized or required by law, will be used only for purposes directly related to administration of the North Carolina Weatherization Assistance Program. I have accepted and understand all Weatherization forms and the Client Education Video (also located on BRCA’s website).
*

AGREE DISAGREE
PERMISSION TO ENTER PREMISES

I understand and agree, if approved for services, that I and the members of my household will adhere to the guidelines of the Weatherization Assistance Program; such guidelines may include, but are not limited to, providing BRCA and/or its representatives with ready access to all areas of the dwelling mutually agreed upon times for the purpose of assessment, performing work, and conducting quality assurance inspections of the service provided.
*

AGREE DISAGREE
PERMISSION TO SHARE INFORMATION WITH COOPERATIVE AGENCIES

I give BRCA permission to share my information with other agencies in order to coordinate services for the benefit of my household. BRCA may provide cooperative agencies information in an effort to qualify my family for services provided through their agency including but not limited to income, household demographics, photographs taken during the commission of weatherization assessments, and other identifying information in order to assist my family with housing, heating, and/or other home rehabilitation services.
*

AGREE DISAGREE
MEDIA CONSENT RELEASE

I hereby consent to participate in interviews, photography, or videos for the purpose of highlighting Blue Ridge Community Action's Weatherization Assistance Program. This consent grants permission to edit, use and reuse information, photographs or videos in print, broadcast, or other forms of media. This release applies to all occupants in the home.
*

AGREE DISAGREE
Application is not complete without Required Documents (Income, Utility Info, Proof of Ownership, etc.)

If you are denied services due to ineligibility, you have sixty (60) calendar days from
denial to ask for a hearing.
Signature *

Sign here with mouse or stylus Clear
Type Applicant Signature *
Date

Month Day Year
Date
Should be Empty:

APPLICANT INFORMATION

DWELLING OWNER INFORMATION

DWELLING AND HOUSEHOLD CHARACTERISTICS

HEATING SYSTEM

AIR CONDITIONING SYSTEM

APPLIANCES

ELECTRICAL

ROOF

PLUMBING

USE THIS TABLE WHEN ESTIMATING WOOD OR KEROSENE COSTS

UTILITY AUTHORIZATION

HOUSEHOLD DEMOGRAPHIC INFORMATION

Family Member 1

Family Member 2

Family Member 3

Family Member 4

Family Member 5

Family Member 6

Family Member 7

HOUSEHOLD INCOME INFORMATION

APPLICATION FOR SERVICES-SUPPLEMENTAL QUESTIONNAIRE

PERMISSIONS AND RELEASES