Weatherization Form Intake Questions

Weatherization Form Intake Questions

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Contact Information
Name*
First Last
Has your home been weatherized in the past 15 years?*
- Yes
- No
- I don't know
Address (must be Ottawa County)*
Street Address Address Line 2 City State ZIP Code
Phone*
Alternate Phone
Do you text?
- Yes
- No
Who is your cell phone carrier?
Email

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Household Information
Please answer the following questions about your household.
Number of Adults (18+) in the home:*
Number of children under 18 in the home:*
List total household gross income amounts for the last 3 months*

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Home Information
Please answer the following questions about your home.
Do you rent or own your home?*
- Rent
- Own
Type of dwelling:*
- House
- Mobile Home
- 2-4 Unit Building
Do you have any mold or mildew in the home?*
- Yes
- No
Do you have infestations of any rodents or insects?*
- Yes
- No
Do you have any structural issues (i.e. – cracked foundation)?*
- Yes
- No
Does your home have knob and tube wiring?*
- Yes
- No
Does your roof or other part of your home have leaks?*
- Yes
- No
Does your home have asbestos or vermiculite?*
- Yes
- No
Do you grow marijuana in the home?*
- Yes
- No
Is the home currently for sale or in foreclosure?*
- Yes
- No
Do you have any plumbing leaks or issues?*
- Yes
- No
CAPTCHA

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