Weatherization Assistance Program

County Number?  24 Greenwood 30 Laurens 19 Edgefield 01 Abbeville 33 McCormick 36 Newberry 41 Saluda 04 Anderson 37 Oconee 39 Pickens    Agency Number

Please provide the following contact information:

Name
Street Address
Address (cont.)
City	State
Zip/Postal Code
Work Phone	Home Phone
E-mail

Age	Applicant's SSN

Applicant's Housing Status:                                                                             Owner Renter

Type of Dwelling that Applicant Lives in:                                                      Brick, Wood, or Vinyl Mobile Home

Elderly (Applicant that is Age 60 or Older):                                                  Yes No

Disabled (Applicant Only):                                                                             Yes No

Children (Applicant that has child(ren) 17 years of age or younger)):         Yes No

Other(Applicant that is a high energy user or has a high energy burden:   YesNo

Has applicant's house been weatherized since 1993?                                   YesNo

Total number of household members? 

Total household monthly income?        

Provide the following information for each household family member:

First Name	Last Name
Age	SSN

First Name	Last Name
Age	SSN

First Name	Last Name
Age	SSN

First Name	Last Name
Age	SSN

First Name	Last Name
Age	SSN

Enter the date: - mm/dd/yy

Disclaimer:

By submitting this form you are hereby agreeing that all information is correct to the best of your knowledge.