Weatherization Application

*Indicates a required field

Your First Name*

Your Last Name*

Your Address*

Your City*

Your State*

Your Zip Code*

Enter your home phone:

Best time to call? AM PM

Enter your cell phone:

Best time to call? AM PM

Email Address*

List your contact person (If we are not able to reach you!)

Contact Name:

Contact Phone:

Are you related to an employee, committee member or board member of La Casa De Esperanza? Yes No

Do you own your home? Yes No

What year was your home built?

If you rent your home, please provide information about your landlord.

Landlord Name:

Landlord Full Address:

Landlord's Phone:

Your Rent Amount:

Is your heat included in your rent? Yes No

Enter your Legal Guardian or Power of Attorney Information (if applicable to you).

Select Your legal representative: Legal Guardian Power of Attorney

Guardian/Attorney Name:

Guardian/Attorney Full Address:

Guardian/Attorney Phone:

Answer questions below about your home to determine your dwelling unit eligibility!

Have you ever applied for Energy Assistance for the current heating season at your current address? Yes No

Is your home currently under any construction or remodeling? Yes No

Is your home currently for sale? Yes No

If you own your home, does your home need other critical repairs for which you would like to request other program information for? Yes No

Has this home received weatherization services before? Yes No