November 2023 - Community Action Council of Howard County

Please provide some basic information about your home. This form is not a substitute for a full application. A Weatherization staff member will let you know if a full application is needed.

Client Information

Name

First

Last

Phone

Address

Address Line 1

City

State

Zip Code

County

Email

Property Information

I am a:

Homeowner
Renter

I have an eviction or foreclosure notice:

YES
NO

Energy Services & Prior Weatherization

I applied for Utility Assistance:

Within the last month
Within in the past year
Never / More than a year ago

I have received a letter from:

OHEP Office of Home Energy Program and/or
DHCD Department of Housing and Community Development
Did not receive a letter

Date you received letter:

I have had Weatherization in the past:

YES
NO

If yes, how long ago and what did they do?

Weatherization Services

Appliances

My water heater is working:

YES
NO

My refrigerator is working:

YES
NO

Cooling

How do you cool your home?

Central AC
Window AC
None

My AC is working:

Yes
No

Electric

My electric company is:

I have a turn off notice from this company / My service is turned off:

YES
NO

Heating

My heat is currently working:

Yes
No
Choice 3

My heat supplier or fuel company is:

I have a turn off notice from this company / My service is turned off:

YES
NO

Structural Condition of Home

My house has the following issue(s):

If you have any other information or concerns about your home, please list them here:

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