*Indicates a required field
Your First Name*
Your Last Name*
Your Zip Code*
Enter your home phone:
Best time to call?
Enter your cell phone:
List your contact person (If we are not able to reach you!)
Are you related to an employee, committee member or board member of La Casa De Esperanza?
Which best describes your home?
Do you own your home?
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.
What year was your home built?
If you rent your home, please provide information about your landlord.
Landlord Full Address:
Your Rent Amount:
Is your heat included in your rent?
Enter your Legal Guardian or Power of Attorney Information (if applicable to you).
Select Your legal representative:
Power of Attorney
Guardian/Attorney Full Address:
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?
Is your home currently under any construction or remodeling?
Is your home currently for sale?
If you own your home, does your home need other critical repairs for which you would like to request other program information for?
Has this home received weatherization services before?