Conservation/Environment

Weatherization Loan Application

Who qualifies for a weatherization loan:

TELL US ABOUT YOURSELF. (fields shown in bold are required)

First Name: Last Name:

Home/Cell Ph: Work Ph: Other Ph:

E-mail address:

PUD Account# (if known):

Site Address (include city & zip):

Mailing Address (include city & zip):

Choose one: Home owner Renter

How did you hear about this program (newspaper ad, radio ad, brochure, Web site,
word-of-mouth, etc)?

TELL US ABOUT YOUR HOME.

What type of home do you have?
Single family residence
Multi-family residence

Describe the style of your home (check all that apply):
Rambler
Manufactured Home
Condo
1 Story
1-1/2 Story
2 Story
A-Frame
Log Home

Check all of the following that apply to your home:
Accessible attic
Crawlspace
Basement
Slab on grade (concrete floor)

What year was the home built?
Number of stories above crawlspace or basement:
Approximate square feet:

Was your home purchased with public funds:	Yes No Unknown
Do your bathrooms have exhaust fans?	Yes No Unknown
Do the bathroom fans exhaust to the outside of your home?	Yes No Unknown
Does your kitchen have an exhaust fan?	Yes No Unknown
Does the kitchen fan exhaust to the outside of your home?	Yes No Unknown
Does your home have knob and tube wiring?	Yes No Unknown
Does your home have recessed lights?	Yes No Unknown

TELL US ABOUT YOUR HEATING SYSTEM.

Check all of the following that apply to your home:

If you have a forced air heating system, where are the ducts located?

ANY ADDITIONAL INTERESTS OR CONCERNS?