Skip to main content

Energy Efficiency Program

Homeowner Application

Energy Efficiency Homeowner Application
First Name
Last Name
Address (Line one)
Address (Line two)
City
Colorado
Zip
Phone Number
How do you prefer to be contacted?

All Household Occupants
List names and Date of Birth (MM/DD/YYYY) of all people who are living in the home. Example: John Smith, 01/02/1983

Black Hills Energy Account Number
Xcel Energy Account Number (For thermostat and/or water heater blanket requests)
Household Information (please select all that apply)
Home Information
If a Mobile Home, please attach a copy of the title below:
No file selected

Energy Efficient Products available
Select the Energy Efficient Items you are interested in below.
Approximately how many standard size light bulbs do you need?
Enter 0 (zero) if not requesting any light bulbs.
Leap
Are you currently approved for LEAP?
If YES, upload your LEAP documentation in the income upload section, no further documentation is needed in the income section.
Please List ALL Monthly household income: Person, Source and Amount
Examples of Income include: Work/Employer, Social Security, Pension/Retirement, Unemployment, Worker's Comp, Child Support/Alimony, Monthly TANF or other income. Example: John Smith, Innovage, $1000/month.

*Please include the name, address, and phone # of any/all employers you may have

Maximum Household Income to Qualify for this Program

1 Person   2 People   3 People    4 People   5 People

$37,760     $43,120    $48,480     $53,840    $58,160

*Based on 80% Annual Household Income for Pueblo County.


Refrigerator Request Information

Is there an existing refrigerator?
Is the existing refrigerator working?
Do not select an option above if there is no existing unit.
Refrigerator Manufacturer Name
Enter N/A if you do not have a existing/working unit.
Refrigerator Model #
Enter N/A if you do not have a existing/working unit.
Refrigerator Serial #
Enter N/A if you do not have a existing/working unit.
Refrigerator Manufacture Year
Do not fill in if you do not have an existing/working unit.
Primary Unit
Is the refrigerator listed above your primary unit?
Do not select an option above if you do not have a existing/working unit.
Old Refrigerator
Do you agree to relinquish your old (10 years or older), inefficient refrigerator?
Do not select an option above if you do not have a existing/working unit.

OWN/RENT     SITE BLT/MODULAR     SENIOR/NOT SENIOR


Evaporative Cooler Request Information

Opening Guidelines
Does your opening meet the Above Guidelines?
If your opening does not meet the guidelines above, the evaporative cooler will NOT fit and we will NOT be able to provide this unit to you.
Faucet
Do you have a water hose faucet (bib) within 50 feet of your opening?
If there is no hose faucet (bib) within 50 feet of the opening we will NOT be able to provide this unit to you.
Electrical Outlet
Do you have a 110 (standard) electrical outlet within 10 feet of the opening?
If there is no 110 (standard) electrical outlet within 10 feet of the opening we will NOT be able to provide this unit to you.

Water Heater Blanket Installation Information

Using the picture below as a reference, please tell us the following information:

What type of hot water heater do you have?
Gallons
Years
Gallons
Years
Years

NOTE: There is a possibility that installing a blanket on your water heater may void its warranty. Please make sure your water heater is not in warranty before you ask for one to be installed.


Thermostat Information

What type of thermostat is currently installed?

NOTE: The installer may need to turn off the power to install the thermostat. The installer will be more than happy to show you how to program it.


NOTE:  If you are using a cell phone camera to take pictures of necessary documentation, please ensure that the photo is clear and that all information is legible. All applications with illegible documentation/pictures will not be accepted.

TIP: Avoid using the camera's flash feature if you are in a bright room.

Current Drivers Licence or Photo ID with address and name matching the applicant.
No file selected
Current, within 60 days, Black Hills Energy Bill matching the name and address of the applicant.
No file selected
Current, within 60 days, Xcel Energy Bill matching the name and address of the applicant.
No file selected
Documents supporting income information given in the income section.
No file selected

By typing my name here, I certify this application for the Energy Efficiency Program and that the above information is true and correct to the best of my ability.

Our Impact in 2017

  • Attended Group & Online Classes

    911

  • New Homeowners

    591

  • Dollars Invested Into Communities

    $101300000

© 2018 NeighborWorks Southern Colorado

Powered by Firespring.org