Application for Weatherization Waiting List

The weatherization program works throughout Clackamas County, helping residents to reduce their heating and cooling costs, and make their homes safer and more comfortable. The program provides free weatherization and energy education to low-income renters and homeowners that qualify.

Name

Address

City

State

Zip Code 97045 / 97045-1234

Phone ###-###-####

E-mail name@example.com

HOUSEHOLD MEMBERS

Number of Over 60

Number of Disabled

Number of Age 18 and under

Number of Veterans

Total Number of Members

TYPE OF HOUSING

Single residence
Duplex
Apartment Complex
Condominium
Mobile home

HEATING FUEL and SOURCE: (Account must be in applicant's name)

Electric
Oil
Gas
Wood
Other

GENERAL INFORMATION

How long have you lived in your home?

Do you own your home or are you buying it?
Own Buying it Neither

Are you renting your home?
Yes No

Does your landlord pay for your heat?
Yes No

Do you live in public housing?
Yes No

Does your home have a basement?
Yes No

Does your home have a crawlspace?
Yes No

Enter the below characters:
Captcha Image

I understand application completion and submission will simply add my home to the weatherization waitlist and that my income will be verified when my name comes to the top of the waiting list. I agree to provide any and all documentation as required when contacted for an eligibility appointment.