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Problems Weatherization Solves: Unhealthy Indoor Air
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PAST 2022 HOLLAND AWARDS EVENT
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PAST 2020 HOLLAND AWARDS EVENT
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May 14, 2024
Why Is My Maryland Home So Hot in the Summer?
May 14, 2024
meghan@energycircle.com
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Weatherization Intake Form
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Step
1
of 5
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
Maryland
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
*
Howard
Anne Arundel
Baltimore County
Baltimore City
Caroline
Carroll
Cecil
Dorchester
Frederick
Harford
Kent
Montgomery
Prince George's
Queen Anne's
Somerset
Talbot
Washington
Wicomico
Worchester
Email
*
How did you hear about us?
*
Email from CAC
Saw an advertisement online
From a friend or family member
Referral from another agency
Other
Next
Property Information
I am a:
*
Homeowner
Renter
I live in a:
*
Single-Family Home
Duplex/Townhouse
Mobile Home
Condo
Apartment
I have an eviction or foreclosure notice:
*
YES
NO
Do you currently receive any of the following? Check all that apply.
Housing Choice Vouchers (HUD)
OHEP Utility Bill Pay Assistance
Supplement Nutrition Assistance Program (SNAP)
Supplemental Security Income (SSI)
Temporary Assistance for Needy Families (TANF)
Maryland Fuel Fund Assistance
Medicaid
DHCD Rehab Program
Baltimore Lead Hazard Control Program
Healthy Homes for Healthy Kids
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Next
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
What do you think your home needs? Check all that apply.
LED light bulbs
Insulation in attic or basement
Programmable thermostat
Showerheads
Clean & tune heating or cooling units
Adjust refrigerator and hot water temperatures
Clean refrigerator coils
Caulking around windows & doors
Smoke & carbon monoxide detectors
New appliances
If you selected "New Appliances" above, please indicate which one(s):
Refrigerator
Clothes Washer
Clothes Dryer
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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
What is the main heating source of your home?
*
Electricity
Gas
Propane
Oil
Wood
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):
*
Missing or broken windows or external doors
Mold or mildew
Active roof leaks
Any damage to ceilings
Electrical violations or hazards
Plumbing leaks, moisture problems
Other health, safety, or structural conditions in your home
None of the above
If you have any other information or concerns about your home, please list them here:
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