HomeWise Weatherization16 of 16

Note: Fields marked with a * are required.

By signing below, I certify that the information provided in this application and the required documentation is complete and accurate. I understand that I may be subject to criminal prosecution if I have knowingly provided false information. I give the City of Seattle permission to request or release information to other non-profit or government organizations to assist me. This information may include but is not limited to, my application including income and related documentation, photographs showing the before and after condition of my home, and Weatherization’s scope of work. Such information may result in my receiving or being denied other City assistance.

For state weatherization programs: I understand that I may request a Fair Hearing if the information I have provided above is not acted on to determine my eligibility within a reasonable time or if I do not receive benefits for which I am eligible. I give the City permission to enroll me in all City or King County assistance programs for which I am eligible.

The utility company(s) may release past and future use information on my household to the City of Seattle’s Office of Housing (OH) HomeWise Weatherization Program. If I am eligible for service, I permit OH, its staff, and contractors to gain access to this property for audit, installation, and inspection purposes. In the case that work requires later inspection from Seattle City Light or the State of Washington, I agree to provide access for these audit purposes. *

First name *

Middle name

Last name *

Please enter the date you signed this form in the format month/day/year *