P.O. Box 46, 301 Louis Street Kingsport, TN 37662 Phone (423)246-6180 Fax: (423) 246-5682 www.uethda.

org

Thank you for your interest in the Weatherization Assistance Program (WAP). Enclosed you will find an
application and various forms. Once the packet is complete, you can either mail it back to our office or drop it
off at the nearest Neighborhood Service Centers located throughout the region. A list of those Centers has
been included.

The following information must be included in the packet. Please review the list carefully. A complete
application with all documents moves much quicker through the eligibility screening process.

*Incomplete or missing forms will be returned*

Checklist of required information

____ Completed application. Please review it carefully and fill out all of the information. Missing information may be
the difference between your home qualifying and not qualifying.

____ Proof of one month’s income for everyone over 14 in your home, both earned (job) and unearned (SS, SSI etc).
You may use check stubs, award letters etc. *Bank statements/W-2s, IRS-1099s are not accepted proof.

____ Proof of residence. Homeowners can submit copy of tax bill, mobile home title or property deed.
Renters will need to have the landlord complete the Landlord Agreement Form.
*Property owner must complete the Permission to Proceed form.

____ Proof of energy cost. Please submit the last 12 months of your energy usage and your most current month’s
Utility Bill. If you use more than one form of energy, please submit both. Ex: propane and electric. You can
obtain this information from your energy provider.

____ Proof of identity. Please include a copy of the applying person’s driver’s license and all household member’s
social security cards.

If you have any questions, please contact Kim Thrasher at 423-230-3718 or

Stop by a Neighborhood Service Center for assistance.

WEATHERIZATION ASSISTANCE PROGRAM (WAP) APPLICATION FOR ASSISTANCE For Agency Office Use Only
◆ Application is not complete without applicant signature on page 2.
DATE APPLICATION RECEIVED:
The applicant must provide proof of identity and citizenship with this application. A driver's license, passport, or other government issued document is acceptable proof DATE APPLICATION COMPLETED:

Has this home been weatherized under the WAP program since September 30, 1994 through any TN WAP Agency? (circle) Yes No APPLICATION TYPE: WEATHERIZATION or RE-WEATHERIZATION
If yes, which agency provided assistance? APPLICATION STATUS: APPROVED or DENIED
If yes, what was the month/year weatherization was performed? JOB # ASSIGNED:

Applicant Name (must provide first and last name): Telephone:

Cell:
Current Home Address: City: State: Zip: County (current home address):

Mailing Address (if different from home address): City: State: Zip:

Emergency/Alternative Contact (Name & phone #):

LIST ALL HOUSEHOLD MEMBERS (INCLUDING APPLICANT). USE ADDITIONAL PAPER IF YOU NEED MORE SPACE
RACE DOES
(Optional to HOUSEHOLD
Provide) MEMBER
White, Black, RECEIVE
Hispanic, REGULAR
Asian/Pacific Citizenship FINANCIAL Has this person received Families
Islander, Native (indicate if U.S. ASSISTANCE First (Temporary Assistance for
SOCIAL American, Citizen, Legal FOR A Needy Families) or SSI benefits
NAME RELATIONSHIP SECURITY DATE OF Native Alaskan, Alien, or Illegal PERMANENT HEALTH within the last 12 months? Please
(must provide first and last name) MARITAL STATUS TO APPLICANT NUMBER BIRTH AGE SEX Other - define Alien) DISABILITY? INSURANCE INCOME mark yes or no
Applicant Name:

Y or N Y or N Y or N
Household Member:

Y or N Y or N Y or N
Household Member:

Y or N Y or N Y or N
Household Member:
Y or N Y or N Y or N
Household Member:
Y or N Y or N Y or N
Household Member:
Y or N Y or N Y or N
Household Member:
Y or N Y or N Y or N
Household Member:
Y or N Y or N Y or N

FAMILY TYPE (check one) DECLARATION OF DISABILITY (Please use additional paper if more space is needed)
LIST THE NAME OF ANY HOUSEHOLD MEMBER WITH A DISABILITY BELOW, AND HOW IT WAS ESTABLISHED (Social Security Disability, SSI, VA, Vocational Rehabilitation, etc..:
Single Parent Female 
Single Parent Male 
2 Parent Household 

Single Person Female (no children) 

Single Person Male (no children) 

More Than One Adult (no children) 

HOUSEHOLD TOTAL INCOME (Below list income information for applicant and all household members). Use additional paper if more space is needed.
GROSS MONTHLY INCOME
NAME SOURCE OF INCOME (provide proof of all income) IF EMPLOYED, PROVIDE EMPLOYER'S NAME & ADDRESS

◄COMPLETE BOTH PAGES►

►NOTE 2: YOU MUST ATTACH INCOME DOCUMENTATION FOR EVERY PERSON IN HOUSEHOLD ◄
HOUSING
 OWN  RENT SQUARE FOOTAGE: YEAR HOME BUILT: ROOF CONDITION: (please circle) POOR FAIR GOOD

EVIDENCE of MOLD or MOISTURE: YES NO

IF OWNER OF HOME, PLEASE PROVIDE THE FOLLOWING INFORMATION: IF RENTING, PLEASE PROVIDE THE FOLLOWING INFORMATION:
NAME (S) ON DEED: LANDLORD NAME (first and last):
DEED BOOK: PAGE: TITLE # if MOBILE HOME: LANDLORD PHONE NUMBER:

LANDLORD ADDRESS:

TYPE OF HOME STRUCTURE (circle one in each column)

FOUNDATION TYPE BUILDING EXTERIOR SINGLE OR MULTI-FAMILY BUILDING TYPE
Crawl Space Brick Exterior Owner Occupied - Site Built
Slab Vinyl Siding Exterior Renter Occupied - Site Built Have you received assistance under the Low Income Home Energy Assistance
Basement Wood Exterior Mobile Home - Owner Occupied Program (LIHEAP)? YES or NO
Mobile Home Skirting Concrete Exterior Mobile Home - Renter Occupied
Other (describe below): Other Exterior - Describe Below Multi-Family - 2 TO 4 Units (enter total units in building: ) Would you be interested in that program? YES or NO
Multi-Family - 5 or more units(enter total units in building: )

HEATING SOURCE: (Circle your primary source)

ELECTRIC NATURAL GAS PROPANE KEROSENE WOOD
Does anyone living in the home have any known or suspected
FUEL OIL COAL OTHER
health concerns?
HOME ENERGY COSTS: $

Utility Company Name: YES or NO (please circle)

Utility Company Address:
Phone #: If yes, please list the name of the household member and their
Account #: health concern:
Utility Company Name:
Utility Company Address: __________________________________________________
Phone #: __________________________________________________
Account #: __________________________________________________
__________________________________________________
(PLEASE ATTACH STUBS, INVOICES, RECEIPTS, ETC FOR ALL ENERGY SOURCES IN THE HOUSEHOLD)
__________________________________________________
I CERTIFY THAT THE ABOVE ACCOUNT(S) IN THE NAME OF __________________________________________________
IS FOR THE USE OF MY HOUSEHOLD AND I AM RESPONSIBLE FOR ITS PAYMENTS. __________________________________________________
IS THIS ACCOUNT IN YOUR LANDLORD'S NAME? Y or N
NOTE: If the energy bill is not in a household member's name, you must provide proof you are responsible for payment of the bill.
Applicant Certification:
I certify that all of the information provided in this application for weatherization assistance is true and correct. I understand that any one who fraudulently covers up a material fact or who knowingly gives false
information for the receipt of weatherization assistance is liable upon conviction to a fine of $10,000 or imprisonment for not more than five years, or both. I authorize the verification of any and all information provided
herein to determine my eligibility, and acknowledge that I have been informed of my appeal rights. I understand that I will be notified in writing of my eligibility status. Pursuant to federal law (5 United States Code
552(b)(6) and 10 Code of Federal Regulations 600.153(f)), identifying information provided by you for determination of your eligibility for Weatherization Assistance and for the provision of services from the program
will be considered confidential and, unless otherwise authorized or required by law, will not be shared with any other persons or agencies except for purposes directly related to the administration of the Weatherization
Program. I do do not agree that the information contained in my application may be shared with other agencies from which I seek additional services.

APPLICANT SIGNATURE: DATE:

NO PERSON ON THE BASIS OF HANDICAP, RACE, COLOR, RELIGION, SEX, AGE, OR NATIONAL ORIGIN WILL BE EXCLUDED FROM PARTICIPATION I N, OR BE DENIED BENEFITS OF, OR BE OTHERWISE SUBJECTED TO DISCRIMINATION IN THE OPERATION OF THE WEATHERIZATION PROGRAM.

To Be Completed By Agency Staff Only:

Total Children under age 6: % OF POVERTY: % OF ENERGY BURDEN:
Total Disabled Members: APS REFERRAL? YES_ NO HIGH ENERGY BURDEN? YES_ NO
Total Age 60 yrs or older: TOTAL PRIORITY POINTS: HIGH RESIDENTIAL ENERGY USER? YES_ NO
TOTAL HOUSEHOLD MEMBERS: CATEGORICALLY ELIGIBLE? YES_ NO
Total # Illegal Aliens in Household:
TOTAL ANNUAL HOUSEHOLD INCOME DETERMINED: $
TOTAL ANNUAL HOUSEHOLD ENERGY COSTS DETERMINED: $
SIGNATURE OF DETERMINING OFFICIAL: DATE CERTIFIED:_
 Homeowner Permission Weatherization Assistance Program
Address:

By signing below, I confirm that:

1. I am the owner of the property listed above,
2. This residence is not currently for sale, nor is it designated for acquisition or foreclosure
by federal, state or local programs.
3. I authorize the Local Weatherization Agency to make arrangements for weatherization
activities, including:
- The inspection of the interior and exterior of my home;
- Photographs to document work;
- The installation of weatherization materials as determined appropriate;
- Upon completion of work, I give permission for the contractor, sub-contractor staff,
local, state, and federal officials to inspect said work.
- I understand the warranty is one year of workmanship with materials being covered
by manufacturers' warranties only.
4. My signature authorizes the Local Weatherization Agency to share my information with
The State of Tennessee, Tennessee Housing Development Agency, Tennessee Valley
Authority, and the U.S. Department of Energy, or their representative, for the purpose of
evaluating the program and energy efficiencies obtained as a result of services provided.
to evaluate the program as well as the program’s effectiveness.
5. I agree to allow the Local Weatherization Agency to share information contained in my
Weatherization Assistance Program application with agencies and/or programs for which
I may qualify for additional services.

Homeowner/Applicant:

Signature Date

WAP Homeowner Permission Form Effective: 07/01/2017

 P.O. Box 46, 301 Louis Street Kingsport, TN 37662 Phone (423)246-6180 Fax: (423) 246-5682 www.uethda.org

RELEASE OF INFORMATION

I, ________________________________________________, hereby authorize the release of

information to the following agencies:

Upper East Tennessee Human Development Agency, Inc.;

The State of Tennessee;
Tennessee Housing Development Agency;
Tennessee Valley Authority (TVA);
U.S. Department of Energy, or their Representative;

for the purpose of determining eligibility for the Weatherization Assistance Program services or
for purposes of evaluation of the program and energy efficiencies obtained as a result of services
provided through this program.

I also authorize this agency to share Information contained in my Weatherization Assistance

Program application or case file with other agencies and/or programs from which I seek
additional services or for purposes of evaluation of the program and energy efficiency.

_______________________________________________ ____________________

Signature Date

Printed Name

Address
 Energy Bill Release Weatherization Assistance Program
Address:

I authorize the release of information pertaining to my energy bills, both past and future, to my
local weatherization agency or its designee for the purpose of obtaining data for the evaluation
of energy conservation effectiveness. I understand that this information will be used only to
provide data for the Program and the information obtained through this release shall not be
made public in such a manner that the dwelling or occupants may be identified.

Energy Provider Name #1:

Account Number:
Name on Account:
Energy Provider Name #2:
Account Number:
Name on Account:

Applicant Signature:
Sign Date

If the Account is not in the Applicant’s name, the Account holder must sign below:

I certify that the energy bill at the above address is in my name but the Applicant listed above is
responsible for payment of the entire bill. I understand that by signing this statement I am
verifying the above named person’s responsibility and acknowledge my acceptance of the
agencies policies and procedures regarding the payment on this account.

Name Signature Date

WAP Energy Release Form Effective: 07/01/2017