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Request Assistance
Weatherization Application
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Weatherization Application
The Weatherization Assistance Program provides homeowners and renters in Clay, Jackson, and Platte counties in Missouri with cost-effective, energy-efficient home improvements at no cost. Bonded and insured professional contractors will do the work to ensure you and your family are living in healthy and safe conditions while lowering your utility bills.
Please submit the following documents with your application:
APPLICATION
Complete, Sign, and Date
SOCIAL SECURITY CARD
Readable copy for main applicant only
UTILITY BILLS
Readable copy (Current Gas Bill & Electric Bill)
PROOF OF INCOME
For all wage earners who live in the home regardless of age – three (3) months prior to application date (Consecutive pay stubs, Current Social Security Award letter, Current Pension Statement, Unemployment letter, Current 1040 Income Tax Return for self-employed individuals)
PROOF OF HOME OWNERSHIP
Recorded Deed (HOMEOWNER ONLY) stating you are the “Grantee”. This can be obtained through the county courthouse through the Recorder of Deeds Department at: www.claycountymo.gov, www.jacksongov.org, or www.co.platte.mo.us
LANDLORD AGREEMENT FORM
(Renter Only)
Failure to submit all documents with the completed application within 90 days of the application date will cause delay and/or denial of service.
Income Guidelines
Number of people in household, monthly income amount/maximum yearly GROSS Income:
Annual Income
1
$30,120
2
$40,880
3
$51,640
4
$62,400
5
$73,160
6
$83,920
7
$94,680
8
$105,440
Applicants cannot receive assistance from this program if the address has been previously weatherized in the last 15 years.
Missouri Low Income Weatherization Assistance Program Application
Answer every question on the application and provide the proper supporting documentation. Leaving questions blank on the application or failing to provide proper documentation will cause delays.
Applicant Information
Your Name
(Required)
First
Last
Phone Number With Area Code
(Required)
Social Security Number (SSN)
(Required)
Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Has the home previously been weatherized?
(Required)
No
Yes
Date Weatherized (if applicable)
(Required)
MM slash DD slash YYYY
Household Information
Type of Home
(Required)
House
Mobile Home
Shelter
Multi-family
Do You Rent or Own?
(Required)
If you own your home, please provide proof of home ownership. (deed, mortgage, title, etc.) If you rent your home, provide your landlord’s address, telephone number and fax number. Upload files on last page of application.
Rent
Own
Household Members
Total Household Members
(Required)
Children 19 and Under
(Required)
Over 60
(Required)
Disabled
(Required)
Native American
(Required)
Household Member Information
(Required)
Add more members using the + icon on the right of each row.
Household Member Name
Date of Birth
Native American (Yes/No)
Handicap or Disabled (Yes/No)
Veteran (Yes/No)
Add
Remove
Income Information
(Required)
Add more income sources using the + icon on the right of each row. Provide proof of income for the previous three months for all household members. If additional space is needed, please attach list (upload files on last page of application).
Income Source
Amount
Interval
Add
Remove
Fuel Consumption Information
Primary Fuel Type
Primary Fuel Supplier
Account Number
Primary Electric Supplier
Account Number
Weatherization Assistance Program Owner/Landlord Agreement Owner/Authorized Agent Certification
Check One
(Required)
Single-Family Unit
Multi-Family (2 -4 Units per Building)
Multi-Family Complex (Five or More Units per Building)
# of Units (Multi-Family)
# of Units (Multi-Family Complex)
How Did You Hear About Us?
Resource Fair
Family/Friend
Text Message
Postcard
Other
Please submit the following documents with your application:
APPLICATION
Complete, Sign, and Date
SOCIAL SECURITY CARD
Readable copy for main applicant only
UTILITY BILLS
Readable copy (Current Gas Bill & Electric Bill)
PROOF OF INCOME
For all wage earners who live in the home regardless of age – three (3) months prior to application date (Consecutive pay stubs, Current Social Security Award letter, Current Pension Statement, Unemployment letter, Current 1040 Income Tax Return for self-employed individuals)
PROOF OF HOME OWNERSHIP
Recorded Deed (HOMEOWNER ONLY) stating you are the “Grantee”. This can be obtained through the county courthouse through the Recorder of Deeds Department at: www.claycountymo.gov, www.jacksongov.org, or www.co.platte.mo.us
LANDLORD AGREEMENT FORM
(Renter Only)
Failure to submit all documents with the completed application within 90 days of the application date will cause delay and/or denial of service.
Upload Documents
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, gif, pdf, Max. file size: 10 MB.
Terms and Conditions
(Required)
I hereby apply for weatherization assistance through the Low-Income Weatherization Assistance Program, or LIWAP, administered by Missouri Department of Economic Development’ Division of Energy and implemented by the weatherization agency with whom I am filing this application. I authorize and direct any federal, state or local agency, organization, business or individual to release to the weatherization agency any information needed to verify my application for weatherization assistance. I further authorize and direct the weatherization agency to release information to other entities for the purpose of determining my household’s eligibility for the LIWAP.
I authorize the release of my billing and utility consumption history from my utility vendors providing service to the residence for which I request weatherization assistance, and those vendors are hereby released from any liability for providing information to the weatherization agency.
I understand information relating to my eligibility application or participation in the program, such as name, address, or income information, are generally exempt from disclosure and requests for such information will be treated by the Department of Economic Development’ Division of Energy consistent with the federal government’s treatment of information requested under the Freedom of Information Act (FOIA), 5 U.S.C. 552, including the privacy protections contained in Exemption (b)(6) of the FOIA. A request for release of my personal information including but not limited to my name, address, or income information requires the Department of Economic Development’ Division of Energy to balance a clearly defined public interest in obtaining this information against my legitimate expectation of privacy. If a legitimate, articulated public interest is found, the Department of Economic Development’ Division of Energy
may release my information in the aggregate with other recipients’ information.
I understand that funds for weatherization assistance for my residence may be provided by federal and state agencies, utility vendors, and other sources, and I hereby agree that my information, to the extent not specifically required to be kept confidential pursuant to the federal Privacy Act and Freedom of Information Act, and Missouri laws including the Sunshine Law, may be released by the Department of Economic Development’ Division of Energy to qualified personnel for research, audits, program evaluation or reports, with appropriate restrictions on the use of that information (i.e., not to be released to the public). If I receive LIWAP services, I specifically authorize the
Department of Economic Development’ Division of Energy to release information regarding my identity, address, weatherization services performed on my residence and other pertinent information, to my utility vendors or other appropriate entities for use in analyzing the effects of weatherization on utility usage, for other research, or for required reporting purposes. This authorization does not constitute public release of my identity, and I understand the Department of Economic Development’ Division of Energy will not publicly release or permit public release of my personnel information, and will place appropriate restrictions on use of my personal information. Highly
sensitive information such as Social Security numbers, income or medical information will be protected from disclosure under the Privacy Act and Freedom of Information Act, as well as the Missouri Sunshine Law.
Civil Rights Statement:
No person will be denied or discriminated against in connection with any program or activity receiving federal financial assistance from the U.S. Department of Energy because of race, color, national origin, age, sex or disability
Access to Residence/Conditions:
I agree and understand the Department of Economic Development’ Division of Energy staff, weatherization technicians and contractors must be given access to all areas of my home during business hours and on a reasonable schedule.
My signature below authorizes the Department of Economic Development’ Division of Energy employees, the weatherization agency employees, contractors and subcontractors to enter my home as needed to perform energy audits, weatherization work and inspections of weatherization work and such persons will not be held liable for any injury or expense incurred by me while participating in this program.
I agree and understand that if my home is deemed unsafe or unacceptable for weatherization technicians, contractors or inspectors to perform their duties due to unsafe or dangerous conditions, presence of debris, clutter, mold, insect/rodent infestation, pets, threat of violence, etc., the project will be postponed until these conditions are corrected.
I agree to allow my home to be photographed for pre-and post-work documentation.
I understand that in order to weatherize my home, holes may be drilled in walls (particularly outside walls) to install insulation. I understand holes will be plugged as part of the weatherization service, but that it is my responsibility to paint the plugs used to fill these holes. I also understand that older vinyl or other siding may be damaged during this process.
Closing Certification:
My signature verifies this residence is not currently for sale, nor is it designated for acquisition, clearance or foreclosure by federal state or local programs, and has not been weatherized previously (unless work was performed prior to Sept. 30, 1994). Upon completion of work, I give permission for the contractor, subcontractor, the weatherization agency employees, the Department of Economic Development’ Division of Energy employees and federal officials to inspect that work.
I certify the information provided in this application is true, correct and complete to the best of my knowledge. I understand that I may be fined, imprisoned or both under state or federal law if I make false statements on this application in order to get benefits I am not eligible to receive. LIWAP service is free of charge, but I understand that if my home is served due to incomplete or incorrect information that would otherwise make my household ineligible, I accept responsibility for paying for services received.
My signature below indicates that I have read, understood and agree to the conditions of this application.
I agree to the terms and conditions.
Applicant Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
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