First Name *

Last Name *

Email *

Phone *

Address

Street Address *

City *

State *

Postal Code *

Are you a Homeowner or Renter *

Homeowner

Renter

Owner First Name *

Owner Last Name *

Owner Phone Number *

Owner Email *

Do you currently live in this home? *

Yes

No

What type of home is it? *

Select an option

How many people live in your household? *

Number of people living in the household

Number of household members with income and aged 18 and older *

On the income step you will need to upload the required income verification documents for each one of these individuals.

Are you currently enrolled in any of these programs?

Supplemental Nutrition Assistance Program (SNAP)

Low Income Home Energy Assistance Program (LIHEAP)

Head Start

Medicaid

Lifeline Support for Affordable Communications (Lifeline)

Food Distribution Program on Indian Reservations (FDPIR)

National School Lunch Program (NSLP)

Women, Infants and Children (WIC)

Housing Improvement Program (HIP)

Housing Opportunities for Persons with AIDS

Supplemental Security Income (SSI)

Weatherization Assistance Program (WAP)

Public Housing (housing owned and operated by Public Housing Authorities)

Low Income Housing Tax Credit (LIHTC)

Privately owned multifamily buildings receiving project-based assistance (Section 8, Section 202, Section 811)

Privately-owned multifamily buildings that house residents receiving tenant-based assistance

None of the above

Annual Household Income *

$

Please include pre-tax income from all sources for all household members with income age 18 and older

Which upgrades are you interested in?  *

I'd like to upgrade my existing gas or electric water heater to an efficient heat pump water heater.

I'd like my home weatherized (adding insulation to the home and sealing air leaks).

Who is your electric utility provider?  *

Please provide the name of the electric utility provider *

Electric account number *

Duke Account First Name *

Duke Account Last Name *

Duke Account Number *

What is your primary heating fuel?  *

Gas Provider *

Select the unit of Measurement of your natural gas bills *

Propane Provider *

Heating Oil Provider *

Signatures *

Clear