Weatherization Assistance | 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 *

How did you hear about us? *

Email from CAC
Saw an advertisement online
From a friend or family member
Referral from another agency
Other

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: *

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

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: *

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

Appliances

My water heater is working: *

My refrigerator is working: *

Cooling

How do you cool your home? *

Central AC
Window AC
None

My AC is working: *

Electric

My electric company is: *

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

Heating

What is the main heating source of your home? *

Electricity
Gas
Propane
Oil
Wood

My heat is currently working: *

My heat supplier or fuel company is: *

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

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:

Updating preview…

This is a preview of your submission. It has not been submitted yet!
Please take a moment to verify your information. You can also go back to make changes.

WEATHERIZATION Intake Form

Client Information

Property Information

Energy Services & Prior Weatherization

Weatherization Services

Appliances

Cooling

Electric

Heating

Structural Condition of Home