Weatherization Form Intake Questions
Weatherization Form Intake Questions
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3
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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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Phone
*
Alternate Phone
Do you text?
Yes
No
Who is your cell phone carrier?
Email
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
*
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
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