Name: * Address: * City: * State: * - - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Zip Code: * Phone: * E-mail: Do you own or rent? Own (You will need to provide proof of ownership later) Rent (We will ask for your landlord's name and phone later) Is your home a single-family home or part of a multi-family unit (such as an apartment building)? Single-family Multi-family Approximately how old is your home? Has your home been weatherized before? Yes No If you answered yes, what year? How many people live in your home? How many are children under 19? How many are adults over 60? How many are disabled? Does your household receive Temporary Assistance for Needy Families (TANF)? Yes No Do you receive Social Security Insurance? Yes No What is the best way to contact you? Phone E-mail Regular mail If you answered phone, what is the best time to contact you? Daytime Evening Weekend Are you interested in receiving information about the following? Other energy assistance programs The Green Impact Zone Your neighborhood association