WARM Program Application-eriecountyhousing

Customer name (On your electric bill)

Account Number (On your electric bill)

Address

Email

Day Phone

Evening Phone

I am interested in hearing more about the weatherization assistance through my Gas Utility. I request that FirstEnergy provide my name, address, phone number and Gas Account number for possible follow up

Gas Company Name (If interested)

Customer Name on gas bill (If Interested)

Account Number on Gas Bill (If Interested)

If you are interested in hearing more about the Pennsylvania Weatherization Assistance Program (WAP), please contact the Erie County and City Weatherization Program at 1-814-665-5161, Ext 120

WARM Eligibility Guidelines

Your Maximum Yearly Household

Household Size Income Before Taxes

1 $27,180

2 $36,620

3 $46,060

4 $55,500

5 $64,940

6 $74,380

7 $83,820

8 $93,260

(for each additional person, add $9,440)

I certify that the total number of people in the household is

I certify that the total household income for the last 12 months was

Do you rent or own your home?

If you rent your landlord is required to complete the "Landlord Agreement Form" found at the link below.

LANDLORD AGREEMENT FORM

Electric Heat?

Electric Hot Water Heater?

Who owns the refrigerator? (only answer if you rent)

Who owns the freezer? (only answer if you rent and have an separate freezer)

Landlord's Name (only answer if you rent)

Landlord's Phone (only answer if you rent)

Landlord's Address (only answer if you rent)

Terms & Conditions

As a participant in the WARM program, I give you permission to do the following 1) share my household records with all parties planning to do work on my home or evaluating how much energy is being saved by that work 2) use, at no charge, any description or pictures relating to the work performed at my home and 3) have a resonable access to my home to inspect the work performed by the weatherization contractor.

I agree to the terms & conditions

Date

Your Signature

*