Show UCAIR Wood Stove Exchange Application

Homeowners Name: _____________________________________________________________________

Address: ___________________________________, City ______________________, ZIP: ____________

Phone Home: ________________________________ Mobile: __________________________________

Email: ___________________________________________________________________________________
Wood burning stove or insert brand and model: __________________________________________
Wood burning stove or insert serial number: _____________________________________________
Annual wood usage: ______________________________________________________________________
I understand this application is for a grant to cover the cost of replacing my wood burning
stove with a gas appliance to reduce emissions and improve air quality. YES NO
I understand these funds are available to home owners, not real estate investors, and the home
must be my primary residence. YES NO
I understand that to qualify for this program, natural gas or propane service must already be
in place at my home. YES NO
I understand this application is for the replacement of an operating wood stove and the wood
stove will be removed from my home and destroyed. YES NO
I understand this application is for a discount coupon for $1,000 to apply toward the costs of a
new gas appliance to replace my wood burning stove and I must pay the balance of the costs of
the new appliance. YES NO
I understand that construction and installation must meet all city and state building and
safety codes. YES NO
I agree to allow inspection and photographs by UCAIR staff of my residence and property to
determine the status of my wood burning stove and to verify that all equipment purchased with
money from this program is properly installed. YES NO
Household Income: Under $20,000 Between $20,000 & $50,000 Above $50,000

____________________________________ _____________ _____________________________________

Applicant (print) Date Signed Applicant Signature
Please call if you have questions - 801 536-0086 Submit Application to Bailey Toolson at
bailey@ucair.org or FAX 801 536-4441 or mail to 195 N 1950 W, SLC, UT 84116 10.16.17

UCAIR Funding Partners