Assessment Application Residential
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1
2ASSESSMENT APPLICATION
Residential
Most New York homeowners can receive a home energy assessment for free or at a reduced-cost through the
Home Performance/Assisted Home Performance with ENERGY STAR
®
program. The assessments are available
on a first come, first served basis. Save time and apply online at
nyserda.ny.gov/apply-online
To qualify, you need to meet these requirements:
1. You must be the owner, or be authorized to sign for the owner, of a 1- to 4-unit residential building.*
2. Your total household income must meet the guidelines on page 2.
3. You must not have previously received a free or reduced-cost assessment on the home listed below.
SECTION A: APPLICANT INFORMATION
First Name
Middle Initial
Last Name
NY
Building Address
City
County
State
Zip
Mailing Address (if different than the above)
City
S
tate
Zip
Primary Phone
Secondary Phone
Email Address
Residential Building Type (5+ units do not qualify)*
q Single-Family Home
2-Family Home
q
q 3-Family Home
q 4-Family Home
q Mobile Home
No
Is your home greater than 3,500 sq
uare feet? q Yes
q
SECTION B: HOUSEHOLD INCOME RANGE
Is your gross annual household income less than $99,600?
Yes
q If no, then please refer to attached chart and indicate your annual household income range below.
q
q ≤ 200% AMI** q
≤ 250% AMI
q ≤ 300% AMI
q ≤ 350% AMI
q ≤ 400% AMI
SECTION C: HOW DID YOU HEAR ABOUT HOME PERFORMANCE WITH ENERGY STAR?
(Optional)
Please select all that apply:
q Print Ad
q TV
q Radio
q Internet
q Event/Home Show
q Neighbor/Friend/Family
q Contractor
Real Estate Professional
q Town, Village, City, County
NYSERDA
q EDGE Regional Outreach Contractor
q
q
q Constituency-Based Organization (CBO) Name: _____________________________________
SECTION D: ELIGIBILITY DECLARATION
By signing below, I certify that the information listed on this form is true and accurate to the best of my knowledge and belief.
I understand that my signature on this form gives permission for NYSERDA, or its designee, to verify my eligibility for a free or
reduced-cost assessment. I understand that false or withheld information may result in penalties.
X
Applicant/Homeowner’s Signature
Date
When complete, please mail, fax, or email the signed application to:
* Condo, co-op, or not-for-profit home owners please
call 855-838-7818 to see if you are eligible.
Mail:
Home Energy Assessments
Fax:
(866) 335-6306
** Area Median Income (AMI) represents the statistical
PO Box 12129
Email:
midpoint in household earnings for each county.
Albany, NY 12212
Need Help? Call (855) 838-7818
q Please send a copy of my home energy assessment Reservation Number to the Home
Performance Contractor that I have chosen below
. NY
SERDA does not assign contractors.
Contractor Name: __________________________________________________
Page 1 of 2
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