Weatherization Program Application

Fill out the online application below or download and print the Weatherization Application (English) or Weatherization Application (Spanish) PDF.

This no-cost program is open to income-qualified households in Jackson County.

Please Note: This program does not provide emergency assistance. Applicants can expect to be on the waitlist for approximately 3 years. Thank you for your understanding.

This application must be completed in full and include a copy of both your power and gas bill. Incomplete applications will be returned.

"*" indicates required fields

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Full name*

Street Address*
Address City ZIP / Postal Code

State*
State

Is your mailing address the same as your physical address?*
Yes
No

Mailing Address*
Street Address City ZIP / Postal Code

State*
State

Phone

Email

Type of Home*
Mobile
Apartment
Stick Built

Own or Rent:*
Own
Rent

Main Heat Source

Secondary Heat:

Please complete for all household members (including you). All income for all members of the household must be listed when applying for weatherization assistance. Please list the gross (before deductions) monthly income, and the source of income (wages, social security, etc.).

Household Members

Your First Name*

Your Last Name

Are you the Head of Household?

Last 4 of Your SS#*

DOB*
MM
DD
YYYY

Gender*

Income Source*

Monthly Income*

If your income is zero and you are over the age of 18, please provide a brief explanation.

Veteran*
Yes
No

Disabled*
Yes
No

Native American*
Yes
No

Tribe

Add Another Household Member*
Yes
No

Household Member's First Name

Last Name

Relation to Applicant

Last 4 SS#

DOB
MM slash DD slash YYYY

Gender

Income Source

Monthly Income

If your income is zero and you are over the age of 18, please provide a brief explanation.

Veteran
Yes
No

Disabled
Yes
No

Native American
Yes
No

Tribe

Add Household Members
Yes
No

Household Member's First Name

Last Name

Relation to Applicant

Last 4 SS#

DOB
MM slash DD slash YYYY

Gender

Income Source

Monthly Income

If your income is zero and you are over the age of 18, please provide a brief explanation.

Native American
Yes
No

Tribe

Veteran
Yes
No

Disabled
Yes
No

Add Another Household Member
Yes
No

Household Member's First Name

Last Name

Relation to Applicant

Last 4 SS#

DOB
MM slash DD slash YYYY

Gender

Income Source

Monthly Income

If your income is zero and you are over the age of 18, please provide a brief explanation.

Native American
Yes
No

Tribe

Veteran
Yes
No

Disabled
Yes
No

Add Another Household Member
Yes
No

Household Member's First Name

Last Name

Relation to Applicant

Last 4 SS#

DOB
MM slash DD slash YYYY

Gender

Income Source

Monthly Income

If your income is zero and you are over the age of 18, please provide a brief explanation.

Native American
Yes
No

Tribe

Veteran
Yes
No

Disabled
Yes
No

Add Another Household Member
Yes
No

Household Member's First Name

Last Name

Relation to Applicant

Last 4 SS#

DOB
MM slash DD slash YYYY

Gender

Income Source

Monthly Income

If your income is zero and you are over the age of 18, please provide a brief explanation.

Native American
Yes
No

Tribe

Veteran
Yes
No

Disabled
Yes
No

Add Another Household Member
Yes
No

Household Member's First Name

Last Name

Relation to Applicant

Last 4 SS#

DOB
MM slash DD slash YYYY

Gender

Income Source

Monthly Income

If your income is zero and you are over the age of 18, please provide a brief explanation.

Native American
Yes
No

Tribe

Veteran
Yes
No

Disabled
Yes
No

Add Another Household Member
Yes
No

Has anyone in your household applied for, or received Energy Assistance?*
Yes
No

How long have you been at this address?*

Landlord information

Landlord/Legal Owner’s name?

Phone

Address
Street Address City State / Province / Region ZIP / Postal Code

Has the home been weatherized in the past 15 years using Federal Funds?
Yes
No

Power Bill*
Max. file size: 1 GB.

Gas Bill (If Applicable)
Max. file size: 1 GB.

CLIENT DISCLAIMER: by signing this form I certify that all information provided is accurate and true to the best of my knowledge. I herby authorize the release of all personal information and records, financial or otherwise collected from this application to Oregon Housing and Community Service Department, its agents, and subgrantees for any legitimate purpose including, but not limited to the purpose of deciding eligibility for any and all utility assistance programs available and for reporting associated with those assistance programs.

Consent*
By checking this box and typing my name below, I am electronically signing this form.

CLIENT DISCLAIMER*
By checking this box and signing this form I certify that all information provided is accurate and true to the best of my knowledge. I herby authorize the release of all personal information and records, financial or otherwise collected from this application to Oregon Housing and Community Service Department, its agents, and subgrantees for any legitimate purpose including, but not limited to the purpose of deciding eligibility for any and all utility assistance programs available and for reporting associated with those assistance programs.

Applicant Signature*

Date*
MM
DD
YYYY

CAPTCHA

Weatherization Program Application

Household Members

Landlord information

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