Weatherization Form Intake Questions Weatherization Form Intake Questions Step 1 of 3 33% Contact InformationName* First Last Address (must be Ottawa County)* Street Address Address Line 2 City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Alternate PhoneDo you text? Yes No Who is your cell phone carrier? Email Household InformationPlease 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 InformationPlease 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
