North Dakota Department of Commerce Division of Community Services: Weatherization Assistance : Submit Application

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	Energy Efficient & Renewable Energy \| Weatherization Assistance \| Submit Application

Submit Application

North Dakota Weatherization Assistance Application Complete the questions below to apply for low-income weatherization assistance. Your application will be forwarded to the Community Action Agency serving your region. Items marked with asterisks are required.
* 1. First Name
* 2. Last Name
* 3. Physical Home Address
4. Mailing Address (Needed only if different than physical home address.)
* 5. City
* 6. Zip Code
* 7. Home Phone
8. The following questions are optional. Please complete as many of the below as possible and click submit at the bottom of this survey to complete the application. Other Contact Number
9. Email Address
10. Have you received Weatherization Assistance in the past?	Yes No
11. Please select the region that includes the county you live in.
12. Do you live on a reservation? If yes, please chose which reservation below.
13. Please provide directions to your home.
14. Total Number of People Living in Household:
15. Number of Persons over age 18 employed:
16. Do you own or rent this residence?	Own Rent
17. What is the total income for all household members living at your residence per month? Must be over 18 years of age unless head of household. Please enter dollar amount.
18. Do you currently get fuel assistance?	Yes No
19. Dwelling Type: Check all that apply.	Single Family Stick Built Mobile Home 2-4 Family Units 5 or more Family Units
20. Heating System: Check all that apply.	Hot Water Hot Air Space Heater Baseboard Electric Other
21. Fuel Type: Check all that apply.	Oil Propane Electric Natural Gas Coal Other
22. Main Supplier for Heat: List name of company.
23. Energy Cost per Year for Heat: You can obtain a billing history from your energy suppliers for the past 12 months.
24. Main Supplier for Electricity: List name of company.
25. Energy Cost per Year for Electricity: You can obtain a billing history from your energy suppliers for the past 12 months.
26. Renters If you are renting please complete the following. Name of Landlord:
27. Landlord Phone Number:
28. Landlord Address include City, State, & Zip:
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