SNAP — Spokane Neighborhood Action Program

Spokane Neighborhood Action Programs Weatherization Program Pre-Application

General Information

Name:
Address:
City/State/Zip:
Home Phone Number:
Work Phone Number:
E-mail Address:
Best Time to Contact You:
Did you receive Energy Assistance (EAP) last season from SNAP?
	Yes No

Household Information

How did you hear about our program?
Number of people in the household (how many people live in the house):
Do you live in a mobile home?
	Yes No
Do you live in a mobile park?
	Yes No
Do you own or rent your home?
	Own Rent
Is your rent subsidized?
	Yes No
What do you pay for rent?
If you rent, please write down your Landlord's name, address, and phone #:

Approx. Monthly Income of Household:
Source of Income:

Heat Information Section

Utility:
	Avista Inland Power Vera Cheney Modern Utility
Acount #:
Heat Type:
	electric gas oil propane wood other
Heating Equipment:
	furnace baseboard wood stove other

Copyright © 2004, Spokane Neighborhood Action Programs