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  • Weatherization Program Application

    Puede traducir este formulario con la bandera de idiomas en la esquina derecha.

  • Effective September 23, 2024

    Thank you for your interest in our Weatherization program! 

    If you have any questions, please contact us at homewx@neighborimpact.org or 541-316-2034.



    In order to process your application, we will need you to complete the enclosed Application form, Weatherization Supplemental form and Declaration of Household Income form.


    All household members 18 and over, currently not in high school, and who currently do not receive income, should be listed on the Declaration of Household Income (DHI) form.

     

    In addition to completed forms, we will need copies of the following documents. Please do not send original documents to us.

    • Proof of gross income for all household members over 18 who are not in high school.
    • Copy of electric bill
    • Copy of gas bill, if applicable
    • Proof of identification for all household members over 18, which can include the following:
      • Driver’s License, Passport, Military ID, State ID/Government issued ID, Birth Certificate, Social Security Paperwork, Tribal ID.
    • Copy of the mortgage statement, deed, or manufactured structure ownership document.
      • Please note that these items must verify the name of homeowner and street address.

     

    If you receive any of the following types of income, please include copies of:

    • Wages - copies of paycheck stubs for 60 days prior to date on application
    • Social Security, SSDI or SSI - current year benefit verification letter
    • Pension – payment statement, award letter
    • Temporary Assistance for Needy Families (TANF) - award letter
    • Alimony or child support - award letter
    • Unemployment – benefit verification letter or award summary

     

    If you rent your home, you must provide your property owner’s information and signature on the Weatherization Supplemental form. We do not provide weatherization to renters without the agreement and permission of their property owner. If you have any questions, please contact us at homewx@neighborimpact.org or 541-316-2034.

    An additional requirement of this program is for at least one household to watch an online energy education video and complete a corresponding online survey. We will contact you about the energy education requirement after your complete application is processed. If you are not able to complete the requirement, please contact us.

    Please note that homeowners, by signing the enclosed Weatherization Supplemental form, agree not to sell their home for one year after the weatherization is completed. A homeowner who does sell their home within one year after the weatherization is completed will be held responsible to repay NeighborImpact all funds spent on weatherizing the home.

    Please note that landlords, by signing the enclosed Weatherization Supplemental form, agree to not raise the rent amount or evict tenant(s) for one year after the weatherization is completed if all other aspects of the tenant agreement remain the same.

    Finally, depending on the condition of your home, NeighborImpact may require applicants to complete necessary repairs prior to proceeding with weatherization. Some examples are clean up of debris or correction of structural, plumbing or electrical issues. You will be provided a list of necessary repairs and a time frame to complete the repairs in writing.

  • 2023-2024 Application Form

    Oregon Housing and Community Services
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  • Declaration of Household Income (DHI)

    This form is required for all household members over the age of 18 who either have:
    1. No income OR
    2. Informal income (get paid cash for work or have other non-wage sources of income).

    Possible Informal Income Sources:

    • Informal child support
    • Can deposits
    • Help from relative, church etc. (for 3 months
      or more)
    • Informal spousal support
    • Selling scrap metal
    • Support from non-wage sources
    • Occasional work for cash
    • Income from a rental property

  • Household Information

  • Homeowner Disclaimer: I understand and agree that no warranties, expressed, or implied, are made by NeighborImpact or its employees to the homeowner for materials furnished or work performed pursuant to this agreement. I agree to release and hold harmless NeighborImpact and its staff from all liability arising out of the performance of said improvements. I grant permission to the NeighborImpact Weatherization Program to apply to the utility for any eligible low-income weatherization utility rebate(s).

    I give permission for NeighborImpact to request from the utility billing history and energy usage, which is used in evaluating the energy conservation effectiveness of work proposed and performed. I further direct my utility and/or fuel companies to make such records available to NeighborImpact. I understand that no information obtained through these releases shall be made public in such a manner that the dwelling or occupants can be identified.

    It is my understanding that I shall not sell the property for one (1) year from project completion. I agree that should I sell or release ownership of the property within one year after any work completed that I will reimburse NeighborImpact for any costs related to services provided.

    I agree to hold to the commitment to not raise the rent or evict the tenant based on the weatherization completed by NeighborImpact for a period of one year. I understand if I fail to repay NeighborImpact in accordance with this agreement, it will be forced to exercise any legal remedies it may have, as part of which it will seek an award of interest, and its costs and attorney fees.

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  • Household Members

    Provide full information for ALL household members other than applicant
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  • Declaration of Household Income (DHI)

    This form is required for all household members over the age of 18 who either have:
    1. No income OR
    2. Informal income (get paid cash for work or have other non-wage sources of income).

    Possible Informal Income Sources:

    • Informal child support
    • Can deposits
    • Help from relative, church etc. (for 3 months
      or more)
    • Informal spousal support
    • Selling scrap metal
    • Support from non-wage sources
    • Occasional work for cash
    • Income from a rental property
  •  - -

  • Declaration of Household Income (DHI)

    This form is required for all household members over the age of 18 who either have:
    1. No income OR
    2. Informal income (get paid cash for work or have other non-wage sources of income).

    Possible Informal Income Sources:

    • Informal child support
    • Can deposits
    • Help from relative, church etc. (for 3 months
      or more)
    • Informal spousal support
    • Selling scrap metal
    • Support from non-wage sources
    • Occasional work for cash
    • Income from a rental property
  •  - -

  • Declaration of Household Income (DHI)

    This form is required for all household members over the age of 18 who either have:
    1. No income OR
    2. Informal income (get paid cash for work or have other non-wage sources of income).

    Possible Informal Income Sources:

    • Informal child support
    • Can deposits
    • Help from relative, church etc. (for 3 months
      or more)
    • Informal spousal support
    • Selling scrap metal
    • Support from non-wage sources
    • Occasional work for cash
    • Income from a rental property
  •  - -

  • Declaration of Household Income (DHI)

    This form is required for all household members over the age of 18 who either have:
    1. No income OR
    2. Informal income (get paid cash for work or have other non-wage sources of income).

    Possible Informal Income Sources:

    • Informal child support
    • Can deposits
    • Help from relative, church etc. (for 3 months
      or more)
    • Informal spousal support
    • Selling scrap metal
    • Support from non-wage sources
    • Occasional work for cash
    • Income from a rental property
  •  - -

  • Declaration of Household Income (DHI)

    This form is required for all household members over the age of 18 who either have:
    1. No income OR
    2. Informal income (get paid cash for work or have other non-wage sources of income).

    If the above two points are not applicable to your household members, no need to complete this form.

    Possible Informal Income Sources:

    • Informal child support
    • Can deposits
    • Help from relative, church etc. (for 3 months
      or more)
    • Informal spousal support
    • Selling scrap metal
    • Support from non-wage sources
    • Occasional work for cash
    • Income from a rental property

  • REQUIRED APPLICANT DISCLOSURES AND APPROVALS

    2023-2024 Season

  • PART 1: APPLICANT NOTICE, PROGRAM DISCLAIMERS, AND APPLICANT RESPONSIBILITIES, WAIVER & RELEASE Effective 10/01/2023

    • I, Applicant, understand that the government energy and weatherization assistance programs are voluntary and my application is subject to a review process to determine my household’s eligibility.
    • I understand that in order for my household’s application to be considered, I must submit a complete application that provides all required information.
    • I understand that I may be required to provide additional information or documentation to determine my household’s eligibility.
    • I understand that my household’s application and additional information or documentation materials will all become part of my household’s application (“Application”).
    • I understand that determinations on assistance eligibility are made by the state’s Oregon Housing and Community Services (OHCS) department in conjunction with contracted subgrantee agencies (“Subgrantees”). 
    • In the event that my household’s Application is denied, I may be entitled to a review of my Application under applicable Oregon Administrative Rules.
    • Upon successful enrollment in the LIHEAP/OEAP programs, I further authorize OHCS and the State of Oregon, including designated subcontractors, and OHCS Subgrantees to release my Application and ongoing LIHEAP/OEAP program benefit information held by OHCS (including its subcontractors and OHCS Subgrantees) to the Energy Services Provider (as defined below) for the purposes of administering, monitoring, researching, and evaluating LIHEAP/OEAP program delivery and efficiency.
    • I declare that the information I provide to complete my Application is true and correct.
    • I agree to comply with the government energy and weatherization assistance program requirements for eligible households.
    • Should I receive any heating and/or cooling equipment as result of my eligibility to these programs, I agree to hold OHCS, its sub-grantees and/or contractors harmless.
    • I agree that I am responsible to return ineligible funds or funds used improperly.
    • I authorize and hold harmless OHCS (including its subcontractors and OHCS Subgrantees) to release my Application and ongoing LIHEAP/OEAP program benefit information up and until one (1) program year following my participation in the LIHEAP/OEAP programs.

    PART 2: APPLICANT NOTICE, WAIVER & RELEASE RELATED TO ENERGY SERVICE PROVIDERS & APPLICANT’S ENERGY SERVICE ACCOUNT INFORMATION

    • I understand that the State of Oregon, including OHCS, its designated subcontractors, and Subgrantees, may request information related to my energy services account(s) (“Account”) from my energy service provider(s), including utility, fuel supplier, vendor, or other similar entity providing similar services (“Energy Services Provider”), once my household applies for energy assistance through one of the energy assistance programs, including but not limited to the Low Income Home Energy Assistance Program (LIHEAP) and Oregon Energy Assistance Program (OEAP).
    • I understand that information related to my Account may be requested by the State of Oregon, OHCS, its designated subcontractors, and Subgrantees for the purposes of, including but not limited to, determining my household’s energy assistance eligibility, and administering, monitoring, researching, and evaluating the energy assistance programs (all of which as determined by OHCS in its sole discretion).
      With my signature, 
    • I acknowledge that I am the account holder (or the account holder’s authorized agent) for the Energy Services Provider Account(s) identified in this Application..
    • I hereby authorize and hold harmless my Energy Services Provider(s) to release and provide any and all information relating to my account, including but not limited to account number, account name, service address, billing dates and amounts charged, information related to collections actions, other miscellaneous account charges and information, or other similar account data as may be requested by OHCS or its designated subcontractor (hereinafter “Account Information”) to the State of Oregon, OHCS, its designated subcontractors, and Subgrantees. I understand and agree, should I receive any heating and/or cooling equipment as a result of any of these programs, I agree to hold OHCS, it’s sub grantees and/or contractors harmless.
    • I hereby authorize and hold harmless my Energy Services Provider(s) for such release of my Account Information for up to two (2) energy assistance program years (10/1 to 9/30) prior to my Application and for three (3) program years (10/1 to 9/30) after my Application is submitted.
    • I hereby authorize and hold harmless the State of Oregon, OHCS, its designated subcontractors, and Subgrantees in the use (as authorized by OHCS in its sole discretion) of my released Account Information.

    PART 3: APPLICANT SIGNATURE

    • With my signature I hereby provide the required authorization, approval and acknowledgments to both PART 1 and PART 2 of this ENERGY/WEATHERIZATION ASSISTANCE APPLICATION REQUIRED APPLICANT DISCLOSURES AND APPROVALS.
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  • Applicant Disclaimer: I agree to allow use of the information collected for all NeighborImpact programs, Oregon Housing and Community Services Department, its agents, and sub grantees for any legitimate purpose including, but not limited to the purpose of deciding eligibility for any and all weatherization assistance programs available, for reporting associated with those assistance programs and for reporting and monitoring associated with those assistance programs. 

    NeighborImpact uses a statewide database called OPUS. My signature below indicates that I consent to my household/family information being entered into OPUS and I am aware that it may be shared with other OPUS partners for the purpose of service delivery.

    I/we certify that the information provided in this application is true and correct as of the date set forth below, and acknowledge my/our understanding that intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Section 1001, et seq. And liability for monetary damages to the Lender, its agents, successors and assigns, insurers and any other person who may suffer any loss due to reliance upon any misrepresentation which I/we have made on this application.

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  • I certify that the information in the Declaration of Household Income (DHI) stated is true and accurate by signing this form. I am under penalty of criminal prosecution if false information results in assistance for which I am not eligible. I also understand that providing false information herein constitutes the act of fraud.

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  • File Uploads

  • Please use the secure file upload feature below to upload the following documents:

    • Proof of income for all household members over 18 who are not in high school
    • Copy of electric bill
    • Copy of gas bill, if applicable
    • Proof of identification for all household members over 18, which can include the following: Driver's License, Passport, Military ID, State ID/Government issued ID, Birth Certificate, Social Security Paperwork
    • Copy of the mortgage statement or deed of home or title of mobile

    If you receive any of the following types of income, please include copies of:

    • Wages - copies of paycheck stubs for 60 days prior to date on application
    • Social Security, SSDI or SSI - current year benefit verification letter
    • Pension – payment statement, current bank statement, award letter
    • Temporary Assistance for Needy Families (TANF) - award letter
    • Alimony or child support - award letter or child support case number
    • Unemployment - benefit print out
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  • Possibly Ineligible - Based on your responses, you may not be eligible for the Weatherization Program. If you have questions about program eligibility, please contact the NeighborImpact Weatherization Program at homewx@neghborimpact.org or by calling (541) 316-2034.

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