Empower New York Program Application Checklist Page 2
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8APPLICATION
EmPower New York Program
The following information will help determine which services are most appropriate for you. In some situations, EmPower
services are provided by agencies of the Weatherization Assistance Program (WAP). This application will serve as an
application for the WAP, and may be forwarded to your local agency for these services. Please print clearly and provide as
much information as possible.
SECTION A: APPLICANT INFORMATION
Name
Address
Apt #
NY
City
State
Zip
County
Primary Phone
Secondary Phone
(include area code)
(include area code)
Email
Mailing Address (if different from above)
Additional Contact Person
Relationship to Applicant
Phone Number
(include area code)
SECTION B: DWELLING INFORMATION
q I own
q I rent
I have lived here ______ years
Approximate age of the home_______________
q Single-Family
q Multifamily ___ # of units
q Manufactured/mobile home q Group home/shelter
If you rent, certain upgrades require owner permission. Please provide owner information below:
Owner’s Name:
Address:
Phone
:
(include area code)
Who pays for the heat at the dwelling?
q I pay
q Owner
Who pays for the electric at the dwelling?
q I pay
q Owner
Does your roof leak?
q Yes
q No
If yes, which rooms: ____________________________________
Do you own your refrigerator?
q Yes
If yes, about how old is it? _______ years
q No
Do you use a second refrigerator?
q Yes
If yes, about how old is it? _______ years
q No
Do you use a separate freezer?
q Yes
If yes, about how old is it? _______ years
q No
SECTION C: HOUSEHOLD DEMOGRAPHICS
Total number of members in the household: ________
Please indicate the number of household members who are:
60 years of age or older _____
Persons with disabilities _____
Native American _____
Children age 17 years or younger _____
EmPower contractors and referring agencies: Print your business or agency name in this box.
EmPower New York P.O. Box 2489 Syracuse, NY 13220-2489
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