WEATHERIZATION DEPARTMENT 700 ANDOVER PARK WEST, STE D • TUKWILA, WASHINGTON 98188

PHONE (206) 214-1240 FAX (206) 214-1259 E-MAIL ENERGYCONSERVATION@KCHA.ORG

KCHA Home Owner Wx Application Cover Letter Rev. 062818

WEATHERIZATION PROGRAM APPLICATION

Enclosed is the King County Housing Authority’s Weatherization Program application packet, you must complete this entire packet.

It is best to print clearly, be accurate, and provide all necessary documentation requested to verify your income, residence and citizenship status. Failure to do so will result in a delay of the delivering of a determination on your application.

All income and utility information needs to be provided for the most recent full 3 months preceding your application.

This entire application can be filled out on your computer for your convenience, and to save paper! You can then send a secure email with all documents, if you have the ability to do so. Do not send your personal information via email without contacting our intake line to setup a secure email connection. You can also make an appointment to deliver them to our office or mail the information, be sure to keep copies of all documentation you send if you choose to print and send or deliver.

If your application is approved, it is valid for one year from the date of approval. If we are not able to serve your home within the first year, you will need to complete an additional application and provide all current information at that time; however, we aim to serve you within the first year to prevent that. Additionally, any changes in income during that time and up until you are served must be reported.

Keep your contact information current; including your phone number, email addresses, etc. If we cannot reach you, it will delay serving your home.

If you have any questions regarding the application, any requirements or documentation needed, please do not hesitate to contact our office at (206) 214-1240 or via email at energyconservation@kcha.org

Thank you,

KCHA Weatherization Team

“We transform lives through Housing”

Wx Application Submittal Checklist Rev. 020419

WEATHERIZATION PROGRAM APPLICATION SUBMITTAL CHECKLIST

Completed Application Packet

☐ Household Information Form ☐ Permission Form for Weatherization and Property Release ☐ Weatherization Program Income Summary and Certification ☐ Utility Release Form (file attached to this PDF for PSE of SCL customers)

Documentation Needed

☐ Income Documentation (Ex: Copies of Paystub from last 3 months, Annual SS Award Letter, etc. See Household Income Summary)

☐ Proof of Residence (Ex: Copy of Driver’s License with current address, Utility Bill, etc.)

☐ Proof of Ownership (Ex: Tax Statement, Mortgage Statement, Mobile Home Ownership, etc.)

☐ Citizenship Documentation ((Ex: Copy of Social Security Card, I-94, Green Card, Birth Certificate, US Passport, Medicare Card.)

☐ Utility Bills from most recent three months (If you have gas and electric through different providers, provide both)

☐ Doctors Referral for Respiratory Illness (If applicable)

☐ EPA Guides Confirmation of Receipt Form

*Primary Applicant:

(Last Name) (First Name) (Middle Initial) *Residence Address:

City, State, Zip:

Mailing Address: (If different)

City, State, Zip:

Lived at Residence: Phone Number: Email:Years: Months:

*Housing Status: Own/buy Rental Subsidized (Sec 8)

*Housing Type: Single Family Duplex Triplex Mobile Home Apt. / Condo

*Income/Benefits: SSI Earned Income TANF Pension GA Self Employed VA Child Support Soc. Sec. Unemployment Military Other

*Total Number of Peopleinthe Household (includingyourself):

*Household’s Monthly Income:

$ Cost per Month:$

Number of Bedrooms:

*Primary Heat Source: Oil Wood

Electric Natural Gas Propane Other

SECTION B: Age & Health InformationNumber of Household Members Age : 0-5 yrs ___ 6-19 yrs ___ 20-59 yrs___ 60+ yrs ___ Who have a disability: ___

Does anyone suffer from a diagnosed respiratory illness?: Yes ___ No ___ If Yes, what illness? _______________________________________________ Do they have a doctors referral stating they have been diagnosed: Yes: ___ No: ___ If yes, include a doctor's referral addressed to KCHA with your application. It must state they are currently being treated for a respiratory illness.

SECTION C: Utility Information

Include all documents for verification

Does everyone in the household have a social security card: Yes ___ No ___If Yes, Inlcude copies of each card or contact us to provide in our office. If No, contact to us to know which documentation to provide.

HOW YOU HEAT YOUR HOME:

Electric - Enter your account number: _____________________________________________

Is your electric account with: PSE ___ Seattle City Light ___ Tanner Electric___ Other: ______________

Natural Gas - Enter your account number: _________________________________________

Sign Utility Release forms included with application for all accounts and include last three months heating bills. (same months as your income documentation)

WEATHERIZATION APPLICATON FORM

SECTION A: Household Contact & Eligibility Information

LIHEAP Policy 1.1.1 Household Information Form Rev. 021319

Client Privacy: Personal information collected, used, or acquired in connection with the Weatherization Program shall be used solely for the purpose of providing weatherization services. KCHA Weatherization agrees not to release, reveal, publish, transfer, sell, or otherwise make known to unauthorized persons a client’s personal information without his or her express written consent or as provided by law. Information collected in connection with this application, and the application itself will be shared, by funding requirements, with Washington State Department of Commerce and its partners, and by applying for Weatherization services through KCHA Weatherization you agree and provide express written consent to do so.

KING COUNTY HOUSING AUTHORITY WEATHERIZATION APPLICATON FORM

*Primary Applicant Last Name *Primary Applicant First Name MI *SSN *DOB

*Relation to Primary Self Spouse Partner Child Other Relative Other Non-Relative

*Gender Male Female

Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Multi-Race Other

Education (24 Years or Older) 0-8 9-12 Non-Graduate High School Graduate/GED 12+ Some Post-Secondary 2 or 4 Year College GraduateIncluded in Calculation Yes No

Disabled Yes No

Ethnicity Hispanic or Latino Not Hispanic or Latino

Military Veteran Yes No

Health Insurance Yes No

* Last Name * First Name MI *SSN *DOB

*Relation to Primary Spouse Partner Child Other Relative Other Non-Relative Secondary Applicant Yes No

*Gender Male Female

Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Multi-Race Other

Education (24 Years or Older) 0-8 9-12 Non-Graduate High School Graduate/GED 12+ Some Post-Secondary 2 or 4 Year College GraduateIncluded in Calculation Yes No

Disabled Yes No

Ethnicity Hispanic or Latino Not Hispanic or Latino

Military Veteran Yes No

Health Insurance Yes No

* Last Name * First Name MI *SSN *DOB

*Relation to Primary Spouse Partner Child Other Relative Other Non-Relative

*Gender Male Female

Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Multi-Race Other

Education (24 Years or Older) 0-8 9-12 Non-Graduate High School Graduate/GED 12+ Some Post-Secondary 2 or 4 Year College GraduateIncluded in Calculation Yes No

Disabled Yes No

Ethnicity Hispanic or Latino Not Hispanic or Latino

Military Veteran Yes No

Health Insurance Yes No

* Last Name * First Name MI *SSN *DOB

*Relation to Primary Spouse Partner Child Other Relative Other Non-Relative

*Gender Male Female

Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Multi-Race Other

Education (24 Years or Older) 0-8 9-12 Non-Graduate High School Graduate/GED 12+ Some Post-Secondary 2 or 4 Year College GraduateIncluded in Calculation Yes No

Disabled Yes No

Ethnicity Hispanic or Latino Not Hispanic or Latino

Military Veteran Yes No

Health Insurance Yes No

* Last Name * First Name MI *SSN *DOB

*Relation to Primary Spouse Partner Child Other Relative Other Non-Relative

*Gender Male Female

Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Multi-Race Other

Education (24 Years or Older) 0-8 9-12 Non-Graduate High School Graduate/GED 12+ Some Post-Secondary 2 or 4 Year College GraduateIncluded in Calculation Yes No

Disabled Yes No

Ethnicity Hispanic or Latino Not Hispanic or Latino

Military Veteran Yes No

Health Insurance Yes No

* Last Name * First Name MI *SSN *DOB

*Relation to Primary Spouse Partner Child Other Relative Other Non-Relative

*Gender Male Female

Race American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Multi-Race Other

Education (24 Years or Older) 0-8 9-12 Non-Graduate High School Graduate/GED 12+ Some Post-Secondary 2 or 4 Year College GraduateIncluded in Calculation Yes No

Disabled Yes No

Ethnicity Hispanic or Latino Not Hispanic or Latino

Military Veteran Yes No

Health Insurance Yes No

Note: All fields designated with an (*) are required information. SSN’s are required every eligible household member. If there is more than 6 people in your household please make a copy of this form and add additional members.

SECTION D: Characteristics of Household

LIHEAP Policy 1.1.1 Household Information Form

Rev. 101718

Exhibit 8.4.1A Property Owner Release Form / Permission for Weatherization Rev. 062918

PERMISSION FORM FOR WEATHERIZATION AND PROPERTY OWNER RELEASE FORM

Address of home ___________________________________ What year was your home built (approximate)? _________

___________________________________

Does your home have? A roof leak? Yes ☐ No ☐ Water in the crawlspace? Yes ☐ No ☐ Any rot/decay or mildew? Yes ☐ No ☐ Plumbing leaks? Yes ☐ No ☐ Moisture noticeable on windows? Yes ☐ No ☐ A furnace which works properly? Yes ☐ No ☐ Termite/carpenter ants? Yes ☐ No ☐ Carpet that has been soaked? Yes ☐ No ☐ Cars parked in attached garage? Yes ☐ No ☐ Indoor pets? Yes ☐ No ☐ Any household member pregnant? Yes ☐ No ☐ Leaks or stains on ceiling? Yes ☐ No ☐ Any household member with asthma, respiratory problems or flu like symptoms? Yes ☐ No ☐ Paints, solvents, thinners, or pesticides stored within the home? Yes ☐ No ☐ Any household members who smoke inside the home? Yes ☐ No ☐

Comments _____________________________________________________________________________________ ___

_________________________________________________________________________________________________

_________________________________________________________________________________________________

For your consideration: 1. Replacing windows is not a routine part of the weatherization since window replacement is not often cost effective.2. Some attic areas are difficult to access in order to install insulation. Access may be necessary through the roof, gable

end and/or the interior. All penetrations are to be properly sealed and holes for ceiling access, if any, drilled andplugged. In these instances the auditor and/or installer is to clarify the access method(s).

3. In order to insulate walls, holes must be drilled either through the outside siding or the inside wall if the contractorcannot remove and replace the siding. In either case, the contractor will plug and patch holes. The homeowner isresponsible for any finishing and painting.

4. When adding floor insulation, additional vents may be added in the foundation. The added vents provide air ventilationand reduce moisture problems.

5. To make your home healthier, it may be necessary to install an exhaust fan, range hood or ventilation system.6. It may be necessary to service or repair the furnace or heating system.7. It may be necessary to make minor repairs to prepare for the weatherization. Minor repairs may include limited roof

patching, dry rot repairs, electrical repairs and pest control.8. The weatherization program may provide a new energy efficient refrigerator if the following two conditions are

satisfied: (1) we must calculate that purchase of a new refrigerator will be cost effective and (2) the existingrefrigerator(s) must be removed and decommissioned by the appliance dealer (so that inefficient refrigerators are nolonger functional).

Exhibit 8.4.1A Property Owner Release Form / Permission for Weatherization Rev. 062918

9. Homes built before 1978 may contain lead based paint and weatherization activities could disturb that paint. On rareoccasions, testing the paint for lead is necessary. If lead exists, the paint is not removed or abated. Instead lead hazardsin the work area are safely removed. The building owner receives copies of initial and follow-up test reports and isresponsible for disclosing to any future workers on the home and renters or purchasers of the home the presence oflead based paint. The typical weatherization project, however, does not require paint testing. Workers follow a “SafeWork Practices” approach to their work, whether lead is known to be present or not, in order to avoid exposinghousehold members to possible lead debris.

Please comment on any concerns regarding weatherization: ______________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

I hereby give my permission for KCHA to weatherize and make any necessary weatherization related repairs to my home. It is understood that the weatherization program will cover the costs of eligible measurers noted above. Only cost effective energy upgrades and necessary related repairs will be addressed.

I understand that I shall make my home available to contractors during regular working hours if and when this weatherization work is performed and shall permit the contractors to use, at no cost, existing utilities at the site, such as; light, heat, power and water necessary to the carrying out and completion of the contract work. I shall also facilitate performance of the work, including removal and replacement of rugs, coverings, and furniture, as necessary. I understand that the failure to abide by these conditions may result in deferrals of work that may have been performed.

I understand that KCHA will need to access my entire home to perform all audits and verifications for work performed; and in that, I must have areas clear for access to windows, crawl spaces, attic accesses, etc, and be accommodating of the agencies time in regards to scheduling and making myself and my home available.

I hereby release and pledge to hold harmless King County Housing Authority and its staff from any liability in connection with the work performed or any act or eventuality arising from the work.

I understand that my participation in the weatherization program is subject to funding availability and that, upon completion of my weatherization project, a minimum of two years must elapse before I may again participate in this program.

Signed _____________________________________ Date _______________________ (Homeowner Signature)

KCHA Wx Program Household Income Summary Checklist Rev. 101218

WEATHERIZATION PROGRAM HOUSEHOLD INCOME SUMMARY

Primary applicants and all household members must report all income.

What is considered Income? (Check all that applies to your household)

☐ All money, wages and salaries, including garnishment. ☐ Self-Employment Income (Self Employment worksheet required) ☐ Rental Property Income (Rental Property worksheet required) Note: Family members cannot lease rooms from an applicant. All income must be counted. ☐ Cash Allowances and Stipends Received (Excluding Food Stamps) ☐ Federal and State aided public assistance programs, general assistance, or other assistance programs based on need. (Such as TANF, EBT Cash Payments, etc) ☐ Annuities, Pensions, Retirement, Social Security, Supplemental Security Income, Veterans or Disability Benefit, Workers or Unemployment Compensation, old age or survivors benefits, strike benefits, representative payee payments paid to the beneficiary. ☐ Payments received for a legally sponsored foster child(ren). ☐ Regularly occurring support payments received into the household, such as child support, spousal support, alimony, refugee sponsor support. ☐ Any allocation, maintenance and support sent from absent military personnel. ☐ Estate Trusts, dividends, interests, inheritance payments, etc. ☐ Scholarships not used for education ☐ Payments received to care for someone within the home who is deemed medically required.

You must provide verification of all income for at LEAST the last three months. This can be done through the examples below, but not limited to:

(Check all that applies to your household for each person) ☐ Copies of Paystubs for the past three months ☐ Most recent years filed Tax Returns when submitted prior to April of the following year.☐Social Security Annual Award Letter ☐Child Support Decree and payment records for payments either made or received. ☐ Alimony Documentation and payment records ☐ Current Unemployment Print Out from Employment Security Dept. ☐ Copies of self-employment records with worksheet and receipts for eligible deductions.

☐ If No Income – Notarized Declaration of No Income

LIHEAP Exhibit 1.1.1 (G) Wx Program Income Summary and Certification Rev. 062918

WEATHERIZATION PROGRAM INCOME SUMMARY AND CERTIFICATION

I certify that I have provided and reviewed the above information on this application, and the supporting documentation requested and is accurate to the best of my knowledge. I understand that I may be subject to criminal prosecution if I have knowingly provided false information. I further understand that I may request a Fair Hearing if the provision of the above information is not acted on to determine my eligibility within a reasonable time or if I do not receive benefits for which I feel I am eligible. I also give my permission for King County Housing Authority to release necessary information to other assistance programs for which I may be eligible that may result in my receiving benefits. I also give my permission for the King County Housing Authority to obtain data from my utility vendor on the annual usage of energy on my home both now and within two (2) years after the weatherization is complete.

PRIMARY APPLICANT SIGNATURE:

DATE:

*Attach all documentation that assists in summarizing the income sources provided in the formabove.

List All Household Members Names:

(Print Clearly)

Date of Birth

**/**/****

*List Income Sources forEach Member:

GROSS Income Amount for LAST THREE MONTHS

1 2 3

Wx Confirmation of Informed Consent Rev. 021319

EPA GUIDES ON POTENTIAL HOME HAZARDS

Washington State Department of Commerce requires us to notify you that there is information available for your review regarding potential home hazards through the Environmental Protection Agency (EPA). Links to the guides are below and available for your review.

Please initial for each guide stating that the King County Housing Authority Weatherization Program has provided you with this information and submit this initialed and signed copy with your application. Hard copies are available for you upon request.

RADON - EPA Booklet; A citizens Guide to Radon Initial

LEAD AWARENESS – EPA Booklet; The Lead-Safe Certified Guide to Renovate Right Initial

MOLD & MOISTURE – EPA Booklet; A Brief Guide to Mold, Moisture, and your Home Initial

ASBESTOS – EPA Information on Asbestos and protecting your Family Initial

I certify that I have received copies of each of these pamphlets & information, via links directly to the EPA website, informing me of potential risks of exposure from renovation activity in my home or unit. I received this information before any work had begun.

Client Name (Print):

Client Signature:

Date:

WEATHERIZATION DEPARTMENT 700 ANDOVER PARK W, STE. D • TUKWILA, WA 98188 PHONE (206) 214-1240 FAX (206) 214-1259

LIHEAP Exhibit 1.1.1 (D) Declaration of No Income

Rev. 070218

Applicant Declaration of No Income Only needs to be submitted if applicable. Submit one copy for each household member who is 18 or

older, is not a full-time student and has no income.

I, __________________________________________do hereby declare that I have not (applicant name)

received any income for the months of: 1. ___________________ 2. ___________________ 3. ___________________

The reason I have not had income for these months is:

I have been meeting my basic living needs for food, shelter and utilities in the following way:

Food:

Shelter:

Utilities:

I certify that the information contained above is complete and accurate to the best of my knowledge. I understand that I am signing this statement under penalty of prosecution if I knowingly give false information which results in assistance received to which I am not entitled.

___________________________________________________________________ Applicant Signature Date

Notary State of Washington County of

I certify that I know or have satisfactory evidence that is the person who appeared before me, and said person acknowledged that they signed this instrument and acknowledged it to be their free and voluntary act for the uses and purposes mentioned in the instrument.

Dated:

(Notary Signature) Title: My appointment expires:

Client Self-Declaration and Personal Information Waiver for Plus Health Weatherization Projects

Asthma

COPD

Other Respiratory Disease: ______________________

______________________________________________________________________________

I certify that the information contained above is complete and accurate to the best of my knowledge and the information within has been voluntarily provided. I understand that by signing this document, and participating in the weatherization plus health program, that my data will be shared and used by the King County Housing Authority, King County Public Health, WA Dept of Commerce, and their evaluation contractors for implementation and evaluation of program impacts until no later than January 1, 2025.

Check if signing for a minor under the age of 18 with one of the above listed medical conditions.

Client Signature Date

Single Family Wx Projects Rev. 021319

I, ___________________________________, do hereby declare that infomration below is

correct and that I suffer from one or more of the following medical conditions:

Last 4 of my SSN: ________________

Home Address: ________________________________________________________________

Complete only if you have answsered "yes" that someone in your home has a respiratory illness. Complete one for each person in your household if there is more than one.

PSE CUSTOMER ENERGY DATA RELEASE FORM Authorization to Disclose Energy Consumption and Cost Data

I, , of NAME (as it appears on PSE bill) TITLE (if applicable)

BUSINESS NAME OF RECORD (if applicable)

hereby authorize PSE to provide energy consumption and cost data associated with the Customer at the Service

Address(es) to:

NAME/TITLE (of authorized agent) COMPANY KCHA

TELEPHONE EMAIL

X check this box to release energy consumption and cost data for all company facilities and meters.

This authorization begins on the date of this release form and ends the earlier of the date that Customer vacates the Address or at such time as Customer ends this authorization by submitting a written notice to PSE.

Provide consumption data for these sites, accounts, or meters (attach additional list if necessary)

PSE Account No. (required)

Meter No. Service Address (“Addresses”)

Customer Release

Customer declares that he/she is authorized to execute this release. Customer further certifies that PSE has authority to disclose energy consumption and cost data associated with Customer at the Address(es) to other persons requesting such information. Customer releases, holds harmless, and indemnifies PSE from any liability, claims, demands, causes of action, damages, or expenses resulting from: (i) any release of information or data pursuant to this authorization and release; (ii) the unauthorized use of this information or data.

SIGNATURE TELEPHONE

Executed this day of , , DATE MONTH YEAR

** If not specified, please return completed form to: energyusagedata@pse.com

N/A

N/A

Seattle City Light

Authorization for Release Of Customer Energy Use/Account Information

Individual

Please fill out this form completely, sign and date it, and return via email or fax to: Email: scl_consumption_requests@seattle.gov or Fax: 206-287-5311

Page 1 of 1

ATTN: CUSTOMER CARE DIVISION

Email: scl_consumption_requests@seattle.gov or Fax: 206-287-5311 This report is not for use with the Energy Disclosure Automated Benchmarking Program.

It is for the consumption history of a single account and should be signed by the Account Holder.

UTILITY ACCOUNT HOLDER INFORMATION AND THEIR AUTHORIZED AGENT (if applicable): Authorization Period: Start Date* Account Holder Name* Premises Address* Account # or Meter # Account Holder Telephone* Account Holder Email Address Authorized Agent Name Relationship to Account Holder Authorized Agent Mailing Address Authorized Agent Email* Additional Comments Authorization Period: End Date*

I hereby authorize Seattle City Light to release the energy use data and/or account information specified to the party identified below, and I agree to release and hold Seattle City Light and the City of Seattle harmless from any liability, claims, or damages related to the release of such data and/or information. If I am not the utility account holder, by signing this document I hereby certify that the account holder identified above has authorized me to submit this Authorization for Release of Information on their behalf.

Enter reporting date range: Release current and/or historical energy use data

Release current and/or historical account information

Provide copy of bill(s) Enter billing date(s)

SEATTLE CITY LIGHT IS AUTHORIZED TO RELEASE BILLING AND CONSUMPTION DATA TO THE PARTY BELOW: Name*

If the Account Holder is also the recipient of the report check box and go directly to signature section

Company* King County Housing Authority Mailing Address* 700 ANDOVER PARK W, SUITE D Telephone Fax Email Address

Account Holder Print Name (or Authorized Agent)

Sign Name Date