Weatherization Assistance Program

Transcription

1 Dear Resident of Montgomery County; You will find enclosed the application for the WAP program that you requested. Please complete this application in its entirety. Please attach income verification documentation. Please sign and date all of the documents. Please include a copy of your utility bills. Return the completed application to our office so that your application can be included in the next prioritization. If you have any question completing this application, please feel free to contact us at, Step by Step Instructions: PLEASE PRINT Part 1 Applicant Name- Enter your full name. Telephone Number- Enter your telephone number, or a number through which you can be reached. Applicant Address- Enter your complete address. Race- Please check the appropriate space. Part 2 Type of Structure- Please check all spaces that apply to your residence. Exterior Type- Please check the space that moist closely represents your residence. Landlord Information, If you Rent- Please provide complete Name, Address, and Telephone Number where your landlord can be reached. Please note that the landlord will have to give their permission before any work can be preformed. It is recommended that you contact your landlord before submitting this application to insure that they are interested in our services. Part 3A Categorical Eligibility- if any member of your household receives SSI or Cash Assistance through Families First. Check yes and attach proper documentation. NOTE: Even if you checked yes under Categorical eligibility, you will still need to complete part 3B. We may use more than one funding source for this program and the individual household member information will be required. Part 3B Income Eligibility- This section must be completed on all applications. Please provide the following information for all individuals living at your residence, including yourself; Individuals Name, Social Security Number, Birth, Individuals Relationship to you, and Individuals Monthly Income. ***Attach Income Documentation for all members of your household*** Part 4 Applicant Certification Statement- Please Read the Certification Statement. Then Sign and date the application. People Helping People, Help Themselves 1 OF 6

2 Part 5 Household information continued- please fill in the appropriate spaces. Number of members in the household including yourself: Number of American Natives in the household: Number of elderly in household, 60 years old or older: Number of Children in household, everyone under 18 years old: Indicate if any of the children in the Household is under the age of six (6). Number of individuals that are handicapped or disabled: What time of day can we call you? Our hours of business are between 8:00 am and 4:30 pm, Monday through Friday. If you can not be reached during this time, please indicate the time that we can contact you and we will make the necessary arrangements. Part 6 Housing information continued- please provide the requested information. We are required to verify ownership and get approval from the legal property owner. If your home is listed at the register of deed's office in someone s name other than your own, please provide that information. (For example if the home is in a parent or child s name). Be sure to use their legal name not a nickname. If you rent, you will need to contact your landlord to find out what name the property is in. The landlord may be using a business name to record the property. If you own your home and have a copy of the deed, or if you own a trailer and have a copy of the title, then please check yes. Have you had previous Weatherization Assistance at any address in this county before? If you have, in what year was the service provided? How old is your home? If you know the year your home was built, please provide that information. If you do not know for sure, please provide your best guess. If you rent. How long do you think you will be at your current address? Due to funding and a backlog of individuals requesting weatherization service, it may be months or even longer before service can be provided. If you anticipate moving during the next 12 months, please indicate this on the application. Also please note that if you are provided with this assistance now, you will not qualify for assistance again for possibly 10 years or longer. For Agency use only- do not do anything in this box: Release of Information and Certification Form- Attached form Please read, sign and return this form with your application. Alien Certification Form- Attached form Please read, sign and return this form with your application. Fuel Release Form- Attached form Please read, sign and return this form with your application. Once again if you have any question completing this application, please feel free to contact us at, People Helping People, Help Themselves 2 OF 6

3 APPLICATION Part 1 Applicant Information (Please Print) Applicant Name: Telephone Number Applicant Address: City State Zip Race ( Check One ): American Indian or Alaskan Native: ; Asian or Pacific Islander ; Black (non-hispanic) ; Hispanic: ; or Caucasian:. (This information is for data collection purposes only). Part 2 Housing Information ( please check as appropriate): Type of Structure: Single Family, Owner Occupied, Rental, Public Housing, Private Multi-Unit, One Story, Two Story, Three Story, Split Level, Mobile Home. Exterior Type: Wood/Masonite, Aluminum/Steel/vinyl Stucco Brick/Stone, None, Other. If you rent your dwelling unit, please provide the following landlord information: Landlord Name: Telephone Number Landlord Address: City State Zip Part 3A Categorical Eligibility Does any member of your household receive Supplemental Security Income (SSI) or cash assistance under the Families First Program: YES NO. If YES, please attach any documentation of this income, and sign and date the statement in Part 4. You do not have to complete part 3B. Part 3B Income Eligibility If no member of your household receives income from SSI or Families First Programs, please complete this part for all household members, and sign and date the statement in Part 4. People Helping People, Help Themselves 3 OF 6

4 Income Relation to Monthly Documentation Name SSN Birthday Applicant Income Attached: Y/N 1. $ 2. $ 3. $ 4. $ 5. $ Part 4 Applicant Certification Statement I certify that all the information provided in this application for weatherization assistance is true and correct. I understand that anyone who fraudulently covers up a material fact or knowingly gives false information for the receipt of weatherization assistance is liable upon conviction to a fine of $10, or imprisonment for not more than five years, or both. I authorize the verification of any and all information provided herein to determine my eligibility, and acknowledge that I have been informed of my appeal rights. I understand that I will be notified in writing of my eligibility status. Applicant Signature Part 5- Household information continued Total Members in Household, Total # of Elderly in Household, Total # of Native Americans in Household, Total # of Children in Household. Total # of Handicapped/Disabled in the Household, Is there a child in the Household under the age of six (6)?, What time of day, Monday through Friday, is the best to contact you?. Part 6 Housing information continued The ownership of all properties must be verified. If your home is registered in someone s name other than your own, please provide that name and explain the reason. This includes rentals check with your Landlord... I hold the Deed/Title to my home. Yes, No. Have we ever provided you with Weatherization Assistance before? Yes, No. If yes, in what year did we provide the service?. Approximately how old is your House/Trailer/Apartment?. If you rent, how long do you anticipate living at this address?. People Helping People, Help Themselves 4 OF 6

5 Part 7 Confidentiality Pursuant to federal law (5 United States Code 552(b)(6) and 10 Code of Federal Regulations (f)), identifying information provided by you for determination of your eligibility for Weatherization Assistance and for the provision of services from the program will be considered confidential and, unless otherwise authorized or required by law, will not be shared with any other persons or agencies except for purposes directly related to the administration of the Weatherization Program. FOR AGENCY USE ONLY Are there any known plans for the government acquisition or clearance of dwelling unit: YES NO ( If YES, the Department of Human Service is to be notified before any action is taken on the application.) Total Annual Household Income Determined: $ Categorically Eligibility: YES NO Application Status: Approved Denied Priority Points: Signature of Determining Official Release of Information and Homeowner Authorized Agency Certification I do hereby authorize the above named agency to take the following actions. 1. To share information contained in my application with other agencies and/or programs from which I seek additional services; and 2. (If property owner) To allow work on the dwelling unit listed on my application in accordance with the following provisions: (a) (b) (c) (d) (e) Allow survey and inspection of dwelling unit inside and outside; Allow installation of weatherization materials required; Allow supervision of installation; Allow follow-up inspection of work; and Such other particulars as may be attached to this agreement. *Note: If an applicant or local contracting agency does not want information regarding an application to be shared with other agencies or programs, then draw a line through the first Statement before the client s signature is made. **Note: If an applicant rents and consents to the release of information, then draw a line through the second statement before the client s signature is made. Signature Applicant or Authorized Agent People Helping People, Help Themselves 5 OF 6

6 Alien Certification I do hereby certify that no member of my household is an alien whose status has been adjusted to lawful temporary or permanent resident under Sections 245A ( Amnesty Aliens ) or 210A (Replenishment Agricultural Works) of the Immigration and Nationality Act, as amended by the Immigration Reform and Control Act of Note: Certain aliens legalized under the Immigration Reform and Control Act of 1986 are temporarily ineligible for WAP assistance. In order to ensure compliance with this policy, all applicants for WAP assistance are required to sign this certification stating that no member of their household is an alien whose status has been adjusted to lawful temporary or permanent resident under Sections 245A (Amnesty Aliens) or 210A (Replenishment Agricultural Workers) of the Immigration and Nationality Act, as amended. If an applicant cannot provide this certification, the local agency will contact appropriate Department of Human services staff for additional guidance. Signature Applicant or Authorized Agent Fuel Release Form I hereby authorize the release of all information pertaining to my fuel bills, both past and future to the Clarksville-Montgomery County, or its designee. Fuel Supplier (s): Name and Address Account Number Electric supplier; Natural Gas supplier; Propane supplier; Other supplier: I understand that this information will be used only to provide data for the Low-Income (WAP) and the Low-Income Energy Assistance Program (LIHEAP) and the information obtained through this release shall not be made public in such a manner that the dwelling or occupants may be identified. Applicant Signiture: People Helping People, Help Themselves 6 OF 6