STATE OF MISSISSIPPI
AMERICA RECOVERY REINVESTMENT ACT (ARRA)
WEATHERIZATION PRE-APPLICATION

PLEASE ANSWER QUESTIONS ABOUT THE HEAD OF HOUSEHOLD
Name: Date of Birth:
Address:
Street and Number County City Zip Code
Phone:
Are you a US Citizen? Yes No
Do you receive SSI? Yes No
ABOUT YOUR HOME
Type of Heat: Electrical Oil/Kerosene Gas Wood
Type of Cook Stove: Electrical Gas
Type of Water Heater: Electrical Gas
Estimate of current utility bills: Electric Bill Gas Bill
Has this home been Weatherized before? Yes No
If yes, what year?
Do you own your home? Yes No
If you answered no, who is your landlord?
Landlord's Name:
Landlord's Address:
Landlord's Phone Number: Cost of Rent: $ per mo.
SOURCES OF ALL HOUSEHOLD INCOME
Total Monthly Household Income: $
For assistance in locating the weatherization agency in your area, please call: 1.800.421.0762

Please list all members of your household here.
Name
Birth Date
Age
Marital Status
Sex
Disabled?
Income

Income for the last past twelve months:
How did you hear about this program?
If completing this form on behalf of someone else, please complete the section below with your information:
Name:
Relationship:

Address:
Phone Number:

This information will serve as a pre-application only. If you are income eligible, you will be contacted regarding scheduling an appointment within five business days to complete the process. You will be sent a denial letter if you are over the income guideline.

I understand that it is unlawful to willfully withhold or make false statement regarding this declaration and that I am subject to prosecution if I do so. I certify that to the best of my knowledge, the information provided in this application is true and correct.