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

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