| 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. |
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| * First Name | |
| * Last Name | |
| * Physical Home Address | |
| Mailing Address (Needed only if different than physical home address.) | |
| * City | |
| * Zip Code | |
| * Home Phone | |
| 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 | |
| Email Address | |
| Have you received Weatherization Assistance in the past? |
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| Please select the region that includes the county you live in. | |
| Do you live on a reservation? If yes, please choose which reservation below. | |
| Please provide directions to your home. | |
| Total Number of People Living in Household: | |
| Number of Persons over age 18 employed: | |
| Do you own or rent this residence? |
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| 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. | |
| Do you currently get fuel assistance? |
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| Dwelling Type: Check all that apply. |
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| Heating System: Check all that apply. |
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| Fuel Type:Check all that apply. |
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| Main Supplier for Heat: List name of company. | |
| Energy Cost per Year for Heat: You can obtain a billing history from your energy suppliers for the past 12 months. | |
| Main Supplier for Electricity: List name of company. | |
| Energy Cost per Year for Electricity: You can obtain a billing history from your energy suppliers for the past 12 months. | |
| Renters If you are renting please complete the following. Name of Landlord: | |
| Landlord Phone Number: | |
| Landlord Address include City, State, & Zip: | |
| * Spam Check | |
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