KING COUNTY WEATHERIZATION PROGRAM APPLICATION

PLEASE PRINT………

Applicant Name _________________________________________

LAST NAME, FIRST NAME

Property Address _________________________________________

City, Zip Code _________________________________________

Mailing Address, If Different _________________________________________

City, Zip Code _____________________________________________

Phone: (__ __ __) __ __ __ - __ __ __ __ Msg. Phone: (__ __ __)__ __ __ - __ __ __ __

Social Security Number __ __ __ - __ __ - __ __ __ __

If not a citizen, have you applied for legal resident status? Yes ___ No ___

Lived at Residence: Years ____ Months _____

Number of People in Household: _______ (including yourself)

Number of Members who are: 0-5 yrs ___ 6-17 yrs ___ 60+ yrs ___

Handicapped ___ Migrant Seasonal Farm Worker ___

Please check one box in Housing Status, Type, Heating Fuel			Please check all appropriate boxes
Housing Status	Housing Type	Heating Fuel	Income/Benefits Type
Own/Buy	House	Electric Oil	SSI Social Security
Rental	Duplex	Nat.Gas Wood	AFDC Unemployment.
Subsidized (Sect 8)	Triplex	Propane Other	GAU Earned Income
	Mobile Home		VA Other
$/Mo. $	Apt.Bldg.

IF YOUR HEATING FUEL IS:

ELECTRIC Enter your electric utility account number here: __ __ __ __ - __ __ __ __ - __ __ __

CHECK ONE: __PSE ELECTRIC __SEATTLE CITY LITE __TANNER ELECTRIC __OTHER _________________

NATURAL GAS Enter your gas utility account number here: __ __ __ __ - __ __ __ __ - __ __ __

Voluntary Data: Female Primary Wage Earner? Yes ___ No ___

Number of Household Members Who are:

Asian ___ Black ___ Hispanic ___ No American Indian ___ S.E.Asian ___ White ___ Other ___

Male ___ Female ___

HOUSEHOLD MEMBERS INCOME INFORMATION

LIST ALL HOUSEHOLD MEMBERS NAMES: (please print)	AGES	LIST INCOME SOURCES FOR EACH MEMBER	GROSS INCOME AMOUNT LAST THREE MONTHS 1 2 3

I certify that I have provided and reviewed the above information on this form which is accurate to the best of my knowledge. I understand that I may be subject to criminal prosecution if I have knowingly provided false information. I further understand that I may request a Fair Hearing if the provision of the above information is not acted on to determine my eligibility within a reasonable time or if I do not receive benefits for which I feel I am eligible. I also give my permission for King County Housing Authority to release necessary information to other assistance programs for which I may be eligible that may result in my receiving benefits. I give my permission for the King County Housing Authority to obtain data from my utility vendor on the annual usage of energy on my home both now and within two (2) years after the weatherization is complete.

APPLICANT SIGNATURE: ___________________________________________ DATE: ______________

OFFICE USE ONLY

TOTAL GROSS _____________ ADJUSTMENT _____________ NET _______________

MONTHS 3 / 12 ADJUSTED HOUSEHOLD MONTHLY INCOME ______________

I VERIFY I HAVE SEEN ALL DOCUMENTS NECESSARY FOR THIS APPLICATION

INTAKE WORKER: _________________________________ DATE: _________________