KING COUNTY HOUSING AUTHORITY

HOUSING REPAIR & WEATHERIZATION

5200 South Center Blvd, Ste 280 TUKWILA, WASHINGTON 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.

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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

5200 South Center Blvd, Ste 280 • SEATTLE, WASHINGTON 98188 PHONE (206) 214-1240 FAX (206) 214-1259

PERMISSION FORM FOR WEATHERIZATION

OWNER OCCUPIED HOUSING

Address of home ___________________________________ When was your 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:

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).
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.
When adding floor insulation, additional vents may be added in the foundation. The added vents provide air ventilation and reduce moisture problems.
To make your home healthier, it may be necessary to install an exhaust fan, range hood or ventilation system.
It may be necessary to service or repair the furnace or heating system.
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.

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

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.
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.

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.

Signed _____________________________________ Date _______________________

(Homeowner)