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  • Weatherization Assistance Application

  • Dear Applicant,
    Enclosed is the application for Weatherization. This application must be completed and returned to our office with all of the needed documents before we can determine eligibility. If you are determined to be eligible, you will receive a notice of eligibility. If you have any questions or need help completing the application please call our Program Assistant, Carol Burnett at 518-943-9205.
    Please make us aware of any previous weatherization done to your home. 


    PLEASE INCLUDE THE FOLLOWING INFORMATION WITH YOUR APPLICATION:
    1. Names and ages of all members of household.
    2. Proof of income for all members of household - This may be in the form of any of the following:
    a. Pay Stubs - If employed the previous 4 weeks from date of application.
    b. Statement from Social Security Administration.
    c. Statement of lnteragency Referral from the Department of Social Services.
    d. lnteragency Referral from Department of the Aging.
    e. Unemployment Benefits - Stubs from previous 4 weeks.
    f. Retirement Benefits - Copy of award notice.
    g. Dividends, interest and rent are all considered income.
    3. Copy of fuel bill and electric bill.
    4. Proof of ownership of the property - This could be in the form of a Deed or Bill of Sale.
    5. Land tax bill or Lot I.D.#


    The steps of Weatherization are as follows:
    1. Application is completed and approved for Weatherization.
    2. The Energy Audit is performed on your home. This is an energy inspection of your home that takes 2 - 4 hours to complete. We ask that you be present for the energy audit.
    3. Weatherization Work is performed on your home. Skilled Weatherization staff and subcontractors perform work.
    4. Post-Inspections all work is inspected after completion by Weatherization Director and the Quality Control
    Inspector. 

    Thank you for your interest in our program. We look forward to reducing your energy costs.

    Regards,
    Eugene Kelly
    Weatherization Director

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  • APPLICATION
    Weatherization Assistance Program
    EmPower New York Program

    The following information will help determine which programs are the most appropriate for you.
    Please print clearly and provide as much information as possible.

    SECTION A: APPLICANT INFORMATION

           
                 
               
    Primary Phone         
    Secondary Phone      
    County      
    Mailing Address (if different from above)                  
    Additional Contact Person      
    Relationship to Applicant            
    Phone Number        
     


       

  • SECTION B: DWELLING INFORMATION

          I have lived here          years. Approximate age of the home          
             # of units                  

    If you rent, certain upgrades require owner permission. Please provide owner information below:       
    Owner's Name:                 
    Address:                                           
    Who pays for the heat at the dwelling?                  
    Who pays for the electric at the dwelling?                     
    Does your roof leak?                
    If yes, which rooms:             
    Do you own your refrigerator:       
    If yes, about how old is it?    years      
    Do you use a second refrigerator:           
    If yes, about how old is it?     years     
    Do you use a separate freezer?          
    If yes, about how old is it?             
     

  • SECTION C: HOUSEHOLD DEMOGRAPHICS   
     
    Total number of members in the household:       
    Please indicate the number of household members who are:
    60 years of age or older                
    Persons with disabilities         
    Native American            
    Children age 17 years or younger       
    OPTIONAL
    Please add any information that we may find helpful in reducing your energy consumption and list occupant health issues or special needs that we need to aware of:      
       

  • SECTION D: ENERGY INFORMATION
    Property Address:      
    My primary heating fuel is:
                                         
    My secondary heating fuel is:
                                         
    Secondary Supplier Name:     Account Number:                      
    My water heater runs on:
                  
        
    ELECTRIC UTILITY: If you are responsible for the electric bill, provide the following:
    Utility Name:         
    Account Number:        If NYSEG or RG&E - POD #   
    GAS UTILITY: If you are a natural gas utility customer and responsible for the bill, provide the following:
    Utility Name:      
    Account Number:       If NYSEG or RG&E - POD #    
    PRIMARY FUEL SUPPLIER: If you heat by a fuel other than natural gas or electricity, provide the following:
    Company Name:        Account Number:        
    Do you have a maintenance agreement for your heating system?          
    If yes, list the name of the maintenance provider:         

    CUSTOMER AUTHORIZATION for Release of Fuel/Energy Bills (for previous two years and future three years)
    My signature below certifies that I am financially responsible for the account(s) listed above. I hereby consent and authorize my electricity and fuel suppliers to release any and all energy consumption information, including account number(s), related to the above property address, to representatives of the Weatherization Assistance Program (WAP), and to the New York State Energy Research and Development Authority (NYSERDA) and /or its designated representatives for the period beginning two years prior to the application date and ending three years after participation in the programs which provide services to my dwelling. I understand that this information will be kept confidential, to the extent permitted by law, and used only for the purpose of determining program eligibility and savings.  

          Pick a Date       
       

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  • SECTION F: INCOME DOCUMENTATION                                                                                                                                                     

     
    A.             Provide a copy of ONE of the following:

    Copy of entire award letter for HEAP, SNAP (Food Stamps), TANF (Temporary  Assistance for Needy Families)  or Supplemental Security Income dated within the past 12 months



     
    B.             Only if you cannot provide one of the documents listed under A, provide income documentation as follows:
    •   All household gross income for the last month: Pay stubs. To obtain monthly income total, if income is:

    -  Weekly: multiply weekly income representing 4 most recent weeks by 4.3

    -  Bi-weekly: multiply 2 most recent consecutive weeks by 2.15

    -  Twice a month: multiply by 2

    •   Social Security and Social Security Disability: copy of award letter

    •   Documentation of all forms of income including disability, worker’s compensation, unemployment, pension, maintenance, child support, annuities, Veteran’s benefits and all other income

    •   Self Employment: IRS Report of Quarterly earnings for the last three months

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  • SECTION G: APPLICANT AFFIRMATION

    I authorize release of my contact information, dwelling information, and income documentation to representatives of NYSERDA, to the Weatherization Assistance Program (WAP) and/or its designated representatives, to any community-based organizations identified on this application, and to my utilities. I understand that the information provided by me will be used only for the purposes of determining eligibility for NYSERDA’s residential programs and financial incentives, eligibility for the WAP, and for estimating and evaluating energy savings. I understand that all information will be kept confidential, to the extent permitted by law. I understand that if energy efficiency services are provided to me through NYSERDA’s EmPower New York program or WAP, there will be no cost to me and that participation in these programs will not affect my social security, public assistance, or any other income.

    I understand that this application does not guarantee that assistance will be granted to me. Whether or not services are provided will depend on the number of applications received and the availability of funds and priorities established by the programs. I also understand that I will not be eligible to receive financial incentives or rebates from an electric or natural gas utility for measures provided at no cost through NYSERDA programs or the WAP.

    I agree to provide NYSERDA representatives, the WAP representatives, and independent participating contractors access to my dwelling, at times that are mutually acceptable, to perform program activities including energy inspections, installation of measures, and Quality Assurance activities. I understand that participating contractors are independent contractors and provide   a one-year warranty on labor for work completed. I further understand that participating contractors and vendors will provide appropriate warranties on any equipment provided and that no additional warranties are provided by NYSERDA or the WAP.

    I subscribe and affirm, under the penalties of law, that the statements made on all parts of this application, including statements made on any accompanying documents, have been examined by me and are to the best of my knowledge true and complete.

    I understand that my signature on this form gives permission for NYSERDA, representatives of the WAP, and their designees, to assure my eligibility for NYSERDA’s programs and the WAP. I consent to any inquiry to verify or confirm the information that I have given. I understand that if I give false information or withhold information in order to receive benefits that I am not entitled to, I can be prosecuted to the fullest extent of the law. I also state that no person named in this application is subject to disqualification for weatherization services under the Immigration Reform and Control Act of 1986 (Public Law 99-063).

     

     



  •    Pick a Date  
     

       Pick a Date   

    Your contact information may be shared with other residential programs within NYSERDA. To opt out of this, please initial here.      

  • AGENCY USE ONLY



    Reviewed By:                              
    Check all benefits that the household receives:              
    On the basis of the information provided by the applicant, the household is determined to be:
                  

    Check here if:  
       

    Additional Comments:            

    Agency Representative Signature:        Pick a Date Title:         
    HOMES AND COMMUNITY RENEWAL       NYSERDA      



  • WEATHERIZATION PROGRAM SURVEY


    EDUCATION:

    How many Adults (Age 24+) Completed Grades?
    0-8      
    9-12/non-graduate/GED      
    12+ some post secondary      
    2 or 4-year college graduate      

    OTHER CHARACTERISTICS:

    How Many People in the Family?
    Have Health Insurance        
    Do Not Have Health Insurance      
    Are Disabled      
    Not Disabled     


     

  • Client Code of Conduct


    As a client I will:

    Treat everyone with respect and courtesy
    Adhere to Community Action policies and guidelines
    Work cooperatively with Community Action staff and volunteers
    Commit no illegal or abusive act
    Not engage in financial transactions with staff or volunteers
    Smoke only in designated area and away from children
    Report any unsafe conditions and accidents to staff as soon as possible
    Sign and abide by the Confidentiality Statement
    Refrain from the possession of all weapons

    Community Action will:

    Provide a safe environment
    Refer clients to other professionals when appropriate
    Provide training, case management, support and assistance
    Treat everyone wit respect and courtesy
    Adhere to Community Action policies and guidelines
    Work cooperatively with clients
    Commit no illegal or abuse act
    Not engage in financial transactions with clients
    Smoke only in designated area and away from children
    Sign and abide by the Confidentiality Statement
    Refrain from the possession of all weapons

    Clients Signature      

    Staff Signature      

    Date   Pick a Date   



  • CONFIDENTIAL INFORMATION RELEASE




    Pick a Date   



    I,      give permission to the staff of Community Action of Greene County, Inc. to exchange information regarding my case with any appropriate social service, child protective service, adult protective service, medical, mental health or counseling agency, educational,housing, day care, employment agency, employer or      .




    Signature:    

    Witness:      





  • ATTACHMENT 1 - Keep for Your Records

    Frequently Asked Questions
    EmPower New York and Weatherization Assistance Program

     

    Are services really free?
    Yes – State residents meeting EmPower New York or the Weatherization eligibility requirements can receive home energy services through the programs at no cost.

     

    Do EmPower New York and Weatherization provide services to renters as well as owners?

    Yes  – both programs provide energy services to anyone who owns or rents a home and meets all of the   eligibility requirements. Owners of rental properties that receive Weatherization funds are generally required to contribute a portion of the cost of the work.

     

    What are some of the no-cost energy services that EmPower New York or Weatherization may provide?

    •    Replacement of old-style light bulbs with high-efficiency lighting.

    •    Replacement of inefficient refrigerators and freezers with new ENERGY STAR® certified models.

    •    Added insulation to keep your home more comfortable.

    •    Strategic air sealing to reduce drafts.

    •    Heating system upgrades and repairs.

    •    Everyday strategies and tips to help you manage your energy costs.

    •    Minor repairs to ensure that the installed energy efficiency materials will perform correctly.

    •    Health and safety measures to help ensure indoor air quality.

    •    Identification of any hazardous conditions discovered during the energy audit.

     

    If I accept work from EmPower New York and/or Weatherization, is a lien going to be on my home? Am I required to pay the program back if I move or my income changes?

    There is no cost or future obligation for eligible residents that participate in EmPower New York or the Weatherization Program.

     

    Do the contractors perform code inspections?

    No – EmPower New York and Weatherization contractors are not Code Enforcement Officials.

     

    Can I hire my own contractor?

    No – all work will be completed by a contractor accredited by the Building Performance Institute (BPI), a national organization that sets the technical standards for contractors in energy efficient building performance, so you know they’re applying the latest knowledge and technology to the energy efficiency of your home.

     

    Can I get paid back for work I have already performed?

    No – EmPower New York and Weatherization cannot reimburse you for work that has already been completed.

  • Privacy Protection Information
    Weatherization Assistance Program

    The New York State Personal Privacy Protection Law (Public Officers Law, Article 6-A) requires in §94(1)(d) that each subgrantee of the Weatherization Assistance Program that maintains a system of records provide each subject from whom it requests information with certain notifications as provided below.

    Name of the agency requesting the information and name of system:
    NYS Homes and Community Renewal - Weatherization Payment and Reporting System

    Agency official responsible for the records: Director, Weatherization Assistance Program NYS Homes and Community Renewal
    38-40 State Street Albany, New York 12207 518-474-5700

    Authority for collection and principal purpose for which the information is collected:
    The Energy Conservation and Production Act (P.L. 94-385) §416 and §417 and the Low-Income Home Energy Assistance Act of 1981 (P.L. 97-35, as amended) require the State to keep records for the purposes of monitoring and evaluation and for the preparation of reports, and that eligibility for the program be established, which requires the collection of personal information, including the Social Security number of the applicant.

    Effects of not providing the requested information:
    If information requested on the Weatherization Application is not provided, the applicant's application may be delayed.

    Routine uses for the collected information:
    This information is used by NYS Homes and Community Renewal and its subgrantees for administration of the Weatherization Assistance Program. Some of the information collected is aggregated and reported to the New York State Office of Temporary and Disability Assistance and to the United States Department of Energy.
    This information may also be used to perform data matches with other state and federal agencies, to verify your eligibility for assistance, and for improving delivery of services and program evaluation. No personally­ identifiable information is used for this purpose.

    Subgrantee Information:

     

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