Weatherization Application

* NOTICE:*
By completing this form does not determine your eligibility for the State of Wisconsin's Weatherization Assistance Program. In order to be qualified for the Weatherization Assistance Program someone in your household must be found eligible for the Wisconsin Home Energy Assistance Program (WHEAP) at the address you are applying for. This form is only to show your interest in the Weatherization Assistance Program, a way for us to determine the dwelling unit eligibility, and to identify the property owner.

* Fields are required fields. You must enter information in these fields in order to submit your application.
To help us in our marketing outreach efforts, please tell us where your heard about Partners' weatherization program?
Heard it from:
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other:
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Your First Name: *
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Your Last Name: *
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Your Address: *
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Your City: *
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Your State: *
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Your Zipcode: *
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Enter your home phone:
Invalid Input. Enter your phone number as (123-456-78900).

Best time to call?
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Enter your cell Phone:
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Best time to call:
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Email Address: *
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List your contact person (If we are not able to reach you!)
Contact Name:
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Contact Phone:
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Are you related to an employee, committee member or board member of Partners for Community Development, Inc.?
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If "YES" enter Name and Relationship:
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Which best describe your home?
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Do you own your home?
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If "YES" provide a COPY of one of the following proof of ownership: Current year property tax bill, Registered of Deeds, Registered of Life of Estate, etc.
Upload Proof:
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What year was your home built? *
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If you rent your home, please provide information about your landlord.
Please note your landlord will be required to contribute 20% of the total project's cost!
Landlord Name:
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Landlord's Address:
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Landlord's Phone:
Invalid Input! Enter phone number as (123-456-7890).

Your Rent Amount:
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Enter your Legal Guardian or Power of Attorney information (if applicable to you).
Select your legal representative:
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(Please note you will need to provide legal documentation)!
Guardian/Attorney Name:
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Guardian/Attorney Address:
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Guardian/Attorney Phone:
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Enter all your fuel suppliers information below here.
Who is your primary heating fuel supplier?
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Heating Account:
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Who is your primary electric supplier?
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Electric Account:
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Have you every have your heating system replaced?
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If "Yes" when?
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Answer questions below about your home to determine your dwelling unit eligibility!
Have you applied for Energy Assistance for the current heating season?
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If you answered "NO", please contact your county WHEAP agency to set an appointment to ensure your eligibility for the State of Wisconsin's Weatherization Assistance Program.

For Manitowoc County - Call (920) 683-2888
For Sheboygan County - Call (920) 208-5946
For Ozaukee County - Call 800-721-3301
For North Milwaukee County - Call (414) 270-4653
Is your home currently under any construction or remodeling?
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If you answer "Yes", please wait to apply until all works has been completed.
Is your home currently for sale?
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If you answered "YES", Partners will NOT be able to move forward with your application!

Please do not submit your application in at this time as Partners will not be able to process your applications!

Thank you!
PLEASE READ EACH ITEM AND SIGN BELOW.


I am authorizing Partners for Community Development, Inc. to provide weatherization services to the dwelling unit at the address shown above. If I am not the owner of the dwelling unit, I authorize the agency to contact my landlord.

I authorize Partners for Community Development, Inc. to contact the Legal Guardian, Power of Attorney, and/or contact I have named above regarding my application for weatherization services, if necessary.

I will cooperate with the agency providing weatherization services. I understand that services are available on the basis of current guidelines and funding availability and that the wait for services may be long. I understand that a successful application does not guaranty that weatherization services will be performed. Your application will remain on file with the Agency as long as you remain eligible for Energy Assistance

I Authorize my fuel supplier(s) and electrical utility company to release account information including fuel consumption records to Partners for Community Development, Inc. so that the agency may obtain energy usage data concerning my dwelling unit.

I certify that the information on this application and all information given in connection with this application are true and complete statement of facts according to my best knowledge and belief. I further certify that I have read and understand the statement on this application and agree to them. I also understand that I may be asked to provide proof of any information given on this application, and that giving false information may result in denial of this application and services.

** By typing in your name in the space below you acknowledged that you have read, understand, and agreed to the above statements.**
Appliicant's Signature: *
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Type in today's date: *
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In order to prevent spam submission, please enter the code you see below in the box to submit your application.
Your Submission Code: *
Your Submission Code:
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