KING COUNTY HOUSING AUTHORITY

HOUSING REPAIR & WEATHERIZATION 5200 SOUTHCENTER BLVD. STE. 280 • TUKWILA, WA 98188 PHONE (206) 214-1240 FAX (206) 214-1259

WEATHERIZATION APPLICANT:

Enclosed is an application for the Weatherization Program that you requested. Please complete the application to the best of your ability, sign it and return it to our office. Please do not forget to complete and sign the “Permission” form. If you are a renter, you will also find a form entitled “Property Owner/KCHA Landlord Agreement”. This form, together with the “Permission” form, must be signed by your landlord and returned with the application.

Along with the application you must submit verification of all household income for the full three months preceding your application.

Acceptable income verifications include:

(1)
Copies of pay stubs
(2)
Letter from social security
(3)
Unemployment printout from Employment Security Dept.
(4)
Self-employment; copies of self-employment records or of annual tax return
(5)
Direct deposit pension or direct deposit social security; the bank statement can be used for verification of pension income and social security income as well as verification of your social security number.

Other verifications that must be included:

(1)
Copy of social security card showing name and social security number
(2)
Address verification; copy of utility bill, preferably from your home heating source, i.e., Puget Sound Energy, Seattle City Light, etc., showing account number, name and address of responsible party living in the home.
(3)
Documentation of household members may be requested at a later date.

All of the applicable preceding documentation must accompany the application to avoid delays in processing your application.

If you have any questions regarding the application or verifications required, please do not hesitate to call Delores Mackey at (206) 214-1240.

Thank you.

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 Rental Subsidized (Sect 8)$/Mo. $ House Duplex Triplex Mobile Home Apt.Bldg. Electric Nat.Gas Propane OilWoodOther SSI Social Security AFDC Unemployment. GAU Earned Income VA Other

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 ___

APPLICATION FORM 8/24/98 OVER

↓

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: _________________

APPLICATION FORM 8/24/98 Side 2

KING COUNTY

HOUSING AUTHORITY

HOUSING REPAIR AND WEATHERIZATION OFFICE

15455 65TH AVE. S., STE. 100, • SEATTLE, WASHINGTON 98188 PHONE (206) 214-1240 FAX (206) 214-1259

PERMISSION FORM FOR WEATHERIZATION
RENTAL HOUSING

Address of home _________________________________________ When was this home built (approximate)? _________

Does your home have: A roof leak? Yes( ) No( ) Water in the crawlspace? Yes( ) No( ) Any rot/decay or mildew? Yes( ) No( ) Plumbing leaks? Yes( ) No( ) Moisture noticeable on windows? Yes( ) No( ) A furnace which works properly? Yes( ) No( ) Termite/carpenter ants? Yes( ) No( ) Carpet that has been soaked? Yes( ) No( ) Cars parked in attached garage? Yes( ) No( ) Indoor pets? Yes( ) No( ) Any household member pregnant? Yes( ) No( ) Leaks or stains on ceiling? Yes( ) No( ) Any household member with asthma, respiratory problems or flu like symptoms? Yes( ) No( ) Paints, solvents, thinners, or pesticides stored within the home? Yes( ) No( ) Any household members who smoke inside the home? Yes( ) No( )

Comments ________________________________________________________________________________________

For your consideration:

  1. Some attic areas are difficult to access in order to install insulation. Access may be necessary through the roof, gable end and/or the interior. All penetrations are to be properly sealed and holes for ceiling access, if any, drilled and plugged. In these instances the auditor and/or installer is to clarify the access method(s).

  2. In order to insulate walls, holes must be drilled either through the outside siding or the inside wall if the contractor cannot remove and replace the siding. In either case, the contractor will plug and patch holes. The homeowner is responsible for any finishing and painting.

  3. When adding floor insulation, additional vents may be added in the foundation. The added vents provide air ventilation and reduce moisture problems.

  4. To make your home healthier, it may be necessary to install an exhaust fan, range hood or ventilation system.

  5. It may be necessary to service or repair the furnace or heating system.

  6. It may be necessary to make minor repairs to prepare for the weatherization. Minor repairs may include limited roof patching, dry rot repairs, electrical repairs and pest control.

    1. The weatherization program may provide a new energy efficient refrigerator if the following two conditions are satisfied:

    2. (1) we must calculate that purchase of a new refrigerator will be cost effective and (2) the existing refrigerator(s) must be removed and decommissioned by the appliance dealer (so that inefficient refrigerators are no longer functional). The owner of the existing inefficient refrigerator shall be the owner of the new efficient refrigerator.
  7. Homes built before 1978 may contain lead based paint and weatherization activities could disturb that paint. On rare occasions, testing the paint for lead is necessary. If lead exists, the paint is not removed or abated. Instead lead hazards in the work area are safely removed. The building owner receives copies of initial and follow-up test reports and is responsible for disclosing to any future workers on the home and renters or purchasers of the home the presence of lead based paint. The typical weatherization project, however, does not require paint testing. Workers follow a “Safe Work Practices” approach to their work, whether lead is known to be present or not, in order to avoid exposing household members to possible lead debris.

  8. Replacing windows is not a routine part of the weatherization since window replacement is not often cost effective.

Please comment on any concerns regarding weatherization: ________________________________________________ _

I hereby give my permission to weatherize my home. It is understood that the weatherization program will cover the costs of eligible measurers noted above. Only cost effective energy upgrades and necessary related repairs will be addressed. Some improvements may require landlord funding contributions, including all or part of costs of furnace replacement, window replacement, significant related repairs, etc. KCHA will communicate with the landlord if funding contributions for specific improvements are necessary.

I hereby release and pledge to hold harmless King County Housing Athority and its staff from any liability in connection with the work performed or any act or eventuality arising from the work.

I understand that my participation in the weatherization program is subject to funding availability and that, upon completion of my weatherization project, a minimum of two years must elapse before I may again participate in this program.

Both the tenant and the landlord (building owner) must indicate their agreement by signing below.

Signed _____________________________ _______ Date____________ (Tenant)

Signed __________________________________ __ Date____________ (Building owner)

Building owner information: Address ______________________________ Phone Number _________________

( ) Single Family ( ) Duplex ( ) Tri-Plex ( ) 4-Plex

WEATHERIZATION PROGRAM PROPERTY OWNER/KCHA WEATHERIZATION AGREEMENT

I, , certify that I am the owner/authorized agent for the property located at

, (address) presently rented by:

Tenant (s) Tenant Rent Contract Rent(subsidized housing only)
1.
2.
3.
4

I authorize the King County Housing Authority (KCHA) to make weatherization related repairs and improvements to my property identified pursuant to the Washington State weatherization Specifications. I hereby release and pledge to hold harmless KCHA, and its staff, from any liability in connection with the work.

In Consideration of the weatherization work to be performed, the parties agree:

  1. “Rent” is defined as the tenant monthly payment to the Owner (non-subsidized housing) or the Contract rent (subsidized housing).

  2. That the rent shall not be raised at any time because of any increase in the value of the rental unit due solely to the weatherization assistance.

  3. That from the effective date of this agreement, and during a period extending through one (1) year following the date of completion of the weatherization work, the amount of rent at all the rental units being weatherized will not be raised for any reason. That at the end of this period the rent shall not be raised for an additional period of one (1) year, except to reflect the tenant’s prorated share of the following expenses actually incurred and documented by the Owner; (i) actual increases in property taxes; (ii) actual cost of amortizing improvements to the property (other than weatherization), which are accomplished on or after the date of this Agreement and which directly benefit the tenant; or (iii) actual increases in expenses of maintaining and operation the property.

  4. The provisions of paragraph 3 may be waived by the Agency in writing if, and only if, the premises are leased under a state or federal rent subsidy program, which restricts the amount of rent the owner may charge, in which case the actual contract rent charged by the owner shall conform to the standards of the rent subsidy program.

  5. That from the effective date of this Agreement, and during a period extending through three (3) years following the date of completion of the weatherization work performed, the owner will not evict terminate, or institute any court action for possession against any tenant or successor tenant, except for good cause pursuant to RCW 59.12.030(3)-(5). (e.g., non-payment of rent, committing waste, maintaining a nuisance).

6. That in the event the owner sells the premises within three (3) years after the weatherization work is completed, the owner will comply with one of the two following conditions:

a) The owner shall repay the KCHA at the date of sale an amount equal to the percentage of the three (3) year/month period remaining, times the full value of the material and labor as documented by KCHA work records, except if should to low-income tenants; or

b) The owner shall obtain, in writing prior to the sale, the purchaser’s agreement to assume the

landlord obligations under this agreement.

The owner shall immediately upon entering into a no-contingent Agreement of sale of the premises, so inform both the KCHA and the tenants, by written notice.

  1. That the present tenants, or any successor tenants during the term of this Agreement, are the intended beneficiaries of this Agreement and shall have a right of enforcement.

  2. That for breach of this Agreement, damages, where not otherwise specified, may be awarded in accordance with applicable law. The prevailing party in any suit to enforce this Agreement shall be entitled to recover his costs and a reasonable attorney’s fee.

  3. That the KCHA shall provide a copy of this Agreement and a synopsis explaining its terms to the present tenants. That the owner shall provide a synopsis explaining the terms of this Agreement to subsequent tenants of the above rental unit, or to the new and subsequent occupants of rental units vacant on the effective date of this Agreement.

  4. That the terms of this Agreement are incorporated into any other lease or agreement between the owner and the tenant, and between the owner and any successor tenant during the terms of this Agreement, and if there is any conflict between the provisions of this Agreement and the provisions of such other lease or agreement, the provisions of this Agreement shall govern. With the exception of the provisions outlined above, all provisions of the Washington State Landlord/Tenant Act (RCW 59.18) shall apply to the owner(s) and tenant(s).

  5. That the provisions of this Agreement are severable. If any provision of this Agreement is found invalid, such finding shall not affect the validity of this Agreement as a whole, or any part or provision hereof other than the provision so found to be invalid.

  6. Failure of KCHA to enforce the Agreement upon breach by the Owner/Agent shall not be construed as a waiver of the Agency’s right to enforce the agreement.

Signed: Date: Owner/Authorized Agent

Address: Phone:

City Zip

Approved by: Date: KCHA Representative