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BLUE VALLEY COMMUNITY ACTION PARTNERSHIP , 620 5th Street, P.O. Box 273, Fairbury, NE 68352

Address

Application Date*

First Name*

Last Name*

Phone Number*

County

Address:

State

Zipcode:

Town

Mobile Home

WEATHERIZATION APPLICATION

I hereby request weatherization of my home. I certify that the information has been given voluntarily and is correct to the best of my knowledge. I understand that making false statements or withholding information is punishable by law. I give permission to Blue Valley Community Action, Inc. to certify my eligibility for weatherization. I understand that any and all information provided to Blue Valley Community Action will be kept in confidence and under no circumstances will information be released without my permission except relevant information to contractors. I will permit inspection of the dwelling by authorized agency, state, or federal weatherization officials.

I understand that neither BVCA nor the contractor is responsible for routine home maintenance during or after completion of weatherization work.

If my home qualifies for the weatherization program, I agree to make available to Blue Valley Community Action, Inc. heating bills (quantity and consumption) prior to and after the weatherization of my home. These bills will be made available from my own personal records or from the utility company.

I understand that I have no legal obligation to pay for the weatherization of my home. The work on my home will be performed free of lien or debt. It is agreed that all precautions will be taken to complete the work with the least possible inconvenience to me and that Blue Valley Community Action, Inc. shall not be held liable for any unintentional damage done by its staff or their subcontractors.

I understand that all necessary information to process my weatherization application will be submitted within 30 days after my application submission. If the necessary information is not received within the 30 days my application will become void and will be put on the denial list.

I certify that I live in the house for which I am making application for weatherization and I intend to continue living in my home after the completion of the weatherization for at least 12 months.

I have no intention and knowledge of Federal, State, or Local Programs designation of my home for acquisition or clearance.

I certify that no member of this household is an alien whose status has been adjusted to lawful temporary or permanent resident status under Section 245A ("Amnesty Aliens") or 210A (Replenishment Agricultural Workers) of the Immigration and Nationality Act.

I have lived in my home for: (Years)

Primary Natural Gas/Propane Supplier

Fuel Type

Account #

I therefore give express permission for weatherization to be done on my house

Application Signature

Signature - Please type your name in the box below. By typing your name you confirm that all information that is being submitted on this form is true and accurate.*

Date*

I AUTHORIZE AN EFFICIENCY INSPECTION ON MY HEATING PLANT. I UNDERSTAND THAT BLUE VALLEY COMMUNITY ACTION PARTNERSHIP WILL ONLY COVER $400.00 FOR NECESSARY REPAIRS ON MY HEATING PLANT. IF REPAIRS EXCEED $400.00 BVCA WILL INSTALL A NEW HEATING PLANT. I ALSO UNDERSTAND THAT WEATHERIZATION CANNOT BE STARTED ON MY HOME WITHOUT THIS INSPECTION.

Client Signature

Please type your name in the box below. By typing your name you confirm that all information that is being submitted on this form is true and accurate.*

Date

A. As Part of the weatherization program vinyl, steel, aluminum, or slate siding may be removed prior to the installation of sidewall insulation. However, removal of your siding may invalidate any existing warranty on the siding. Removal of siding under warranty is completely voluntary, therefore:

I wish to have my siding removed and the sidewalls insulated.

I do not wish to have my siding removed and the sidewalls insulated

Client Signature

Please type your name in the box below. By typing your name you confirm that all information that is being submitted on this form is true and accurate.*

Date

Legal Description of Property

Identification or serial number of mobile home:

RECERTIFICATION

This application is a recertifcation for my application that was expired in the Weatherization program. Recertifying my application will put my status in the same order as it previously was.

Client Signature

Please type your name in the box below. By typing your name you confirm that all information that is being submitted on this form is true and accurate.

Date