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Full Name of Applicant (must be owner of building) Social Security Number Birth date
Mailing Address (if different from residence) (Number & Street) City State Zip
2. Do you have other heating equipment (used or unused) in the building? ❏ Yes ❏ No ❏ Don’t know
If so, specify:
❏ Oil Furnace ❏ Gas Furnace ❏ Wood Furnace ❏ Other (specify)
❏ Oil Space Heaters ❏ Gas Space Heaters ❏ Wood Stove / Insert
3. Does the building consist of more than one living unit (apartment, duplex, etc.)? ❏ Yes ❏ No ❏ Don’t know
If so, how many units are there in the building?
If so, how many stories are there in the building?
How did you hear about our WEATHERIZATION program? (Please check all that apply.)
o Ad (TV, print, etc.) o PUD Bill Insert o PUD Brochure o Contractor or Retailer o Friend or Family o Email o PUD Web site
o “Current” Magazine o PUD Employee o Fair or Event o Community Power! o Energy Hotline o Letter o News story
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Signature of Owner or Authorized Representative Date
Please send completed paperwork to:
ATTN: Residential Services, Snohomish County PUD, PO Box 1107, Everett, WA 98206-1107
THE FOLLOWING INFORMATION IS REQUIRED ONLY FOR LOAN APPLICANTS
NOTE: HOMES on leased or rented land are not eligible
1. A copy of your ownership document (e.g., Deed of Trust, Statutory Warranty Deed, Warranty Deed, Title, etc.)
3. If you are signing for an owner, provide a copy of a notarized and recorded Power of Attorney.
Questions?
Energy Hotline: 425-783-1700
(Monday through Friday, 8 am to 5 pm, toll-free in Western Washington at 1-877-783-1000, extension 1700)
Name of Applicant (must be owner of building; list additional owners below) Social Security Number Birth Date
Mailing Address (if different from residence) (Number & Street) City State Zip
Names of Additional Owners (MUST INCLUDE BIRTH DATE & SOCIAL SEC. #) Birth Date Social Security Number
OTHER OWNERS
2. Do you own or lease/rent the land that the building to be weatherized ❏ Own ❏ Lease/Rent
is situated on?
IMPORTANT: PUD AUTHORIZATION IS REQUIRED BEFORE ANY WORK IS STARTED OR SUPPLIES PURCHASED.
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Signature of Owner or Authorized Representative Date