CEO People Helping People
 

Weatherization PreScreening

*Last Name:
*First Name:
E-mail:
*Street Address:
*City / Town:
*ZIP CODE:
*County:
*Phone / Contact Number with Area Code:
Single Family Home? (Multi-family housing with more than 4 units are not eligible properties):
*Homeowner / Renter:
If renter, who pays heat bill, landlord or renter?:
If renter, who pays electric bill, landlord or renter?:
*Total number of persons in household:
*Number of children under age 19:
*Number of elderly persons in household (60 or older):
*Does anyone in the household receive disability income?:
*Type of Heat in the Residence (oil, gas, electric, coal, propane):
*Who is Your Electric Utility Company? (UGI or PPL):
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


* - denotes required field

Commission on Economic Opportunity Weatherization