Weatherization Works!
Weatherization PreScreening

* Last Name:  
* First Name:  
* Street Address:   
* City / Town:  
* County:  
* Phone / Contact Number with Area Code:  
* Homeowner / Renter:  
If renter, who pays heat bill, landlord or renter?:  
If renter, who pays electric bill, landlord or renter?:  
* Years at residence:  
* Has weatherization been done before?:  
* Total number of persons in household:  
* Number of children 12 years of age or younger:  
* Number of elderly persons in household (60 or older):  
* Number of disabled persons in household that receive a disability income:  
* Type of Heat in the Residence:  
* Who is Your Utility Company?:  

Please check the box(es) if a household member is receiving any of the following:

TANF Benefits from the County Assistance Office
SSI Benefits
LIHEAP Fuel Grant

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