Revised 10/2008

Intake Form

Intake Date: ___/___/___

Status

First Name

M.I.

Last Name

SSN#

Reason

Date of Birth

Gender

HOH

M/F/U

AD2

M/F/U

SIB1

M/F/U

SIB2

M/F/U

SIB3

M/F/U

SIB4

M/F/U

SIB5

M/F/U

Mailing Address:
Address: ______________________________________
City/State/Zip code: _____________________________

Cell: (____) ____________________________________

Elementary School District: ________________________
Physical Address:
Address: ______________________________________

Eth

Char

Lang

Edu

Rel

Demographics:

Marital Status:

Home: (____) __________________________________

Work: (____) _______________________ ext. _______

Race

Divorced

Legally Separated

Married

Partner

Single

Widowed

Tribe: ______________________________________________________
Family Type:

Foster Parent (w/foster child(ren))

Grandparent

Married (living w/children)

Married (Spouse in Nursing Home)

Multiple Adults (living w/children)

Multiple Adults (no children)

City/State/Zip code: _____________________________

Single parent-female (living w/children)

Home: (____) __________________________________

Single person (living alone)

Single parent-male (living w/children)

Work: (____) _______________________ ext. _______

Cell: (____) ____________________________________
County: _______________________________________

Living Arrangements:

Homeless

Homeless by Choice

Living w/friends or family

Own

Rent-Subsidized (HUD, Section 8)

Rent-Unsubsidized

Transitional/Shelter

Revised 10/2008

Intake Form

Residence:

Structure:

Wood Frame

Brick

Mobile Home

Multi-Unit

Home # of Stories:

Masonary

Residence-Energy:

Primary Heating:
LP Gas

Electric
Natural Gas

Fuel Oil

Kerosene

None

Other

Wood/Coal

Dwelling Type:

Site Built (single family)

Multi-Family Unit (apartments)

Doublewide

Primary Heating Vendor: _______________________________________

Mobile Home

Primary Heating Account: _______________________________________

Modular Home (no wheels)

Duplex (2 homes under 1 roof)

Row House

3 to 4 Unit Rental

Shelter

Transitional

Other

City/Town

Rural Area

Suburb

Do You Live In?

Secondary Heating:
LP Gas

Electric

Natural Gas

Fuel Oil

Kerosene

None

Other

Wood/Coal

Year of home construction: ______ If unknown, approximate age: _______

Check boxes if the answer is YES for the following questions:
Smokers in Household?

Secondary Heating Vendor: ____________________________________

Secondary Heating Account: _____________________________________

Has Dwelling previously been Weatherized by DOE funds? If so, when? ____
If yes, answer the following questions:
Was dwelling subsequently damaged by an Act of God? If so when? _____
Monthly Cost of Residence: _______
Does Government pay any of rent or house payment?

Heating Source:
Hot Water
Space Heater

Coal
Natural Gas
Steam

Fuel included in rent?

Cooling Energy:

Electric

Electric (hot air)

Other

Propane

Stove

Wood

Revised 10/2008

Intake Form

Employment Information-HOH

Employment Status:

Full Time w/benefits

Full Time w/o benefits

Part Time w/benefits

Part Time w/o benefits

Employment Verification Tool:

Letter from Employer

Employment Information-AD2

N/AUnemployed

Income Verification Tool:

Direct Deposit Receipt
Social Security Statement

Phone Call to Employer

Payroll Check Stub

W-2

RaceA-Asian

Part Time w/benefits

Part Time w/o benefits

Employee ID Badge

Payroll Check Stub

Direct Deposit Receipt

Phone Call to Employer

Bank Statement
Letter from Employer

Social Security Statement

Payroll Check

W-2

Employer:
Employer Phone: (

Employed Since: ____/____/____

CODES:
Reason for SSNC-Confidential
N-Not Collected by
Head Start
UC-Unavailable
cannot provide
UI-Unknown client
import
UW-Unknown will
provide
F-SSN reported
P-Partial SSN reported
R-Refused

Letter from Employer

Stub

Employer:
Employer Phone: (

Full Time w/o benefits

Income Verification Tool:

Bank Statement
Letter from Employer

Full Time w/benefits

Employment Verification Tool:

Employee ID Badge

Payroll Check Stub

Employment Status:

N/AUnemployed

M-Bi-racial/ Multiracial
AA-Black/African
American
C-Caucasian/ White
H-Hispanic
N-Native American
P-Pacific Islander
U-Unknown
EthnicityU-Unknown
H-Hispanic or Latin
N-Not Hispanic or
Latin

Employed Since: ____/____/____

Characteristics
A-Applicant
DB-Debarred
DE-Deceased
D-Disabled/
Handicapped
E-Eviction
FY-HS FD/FY
Exception
OI-HS OI Exception
M-Notice/Delinquent
Mortgage
H-Health/Weather
Related Illness
K-Hurricane Katrina
Evacuee

MW-Migrant/
Seasonal Worker
NH-No Health
Insurance
NC-Non Federal-Crisis
PM-Pregnant Mom
EHS
V-Veteran
Language
A-African
C-Caribbean
CR-Creole
EA-East Asian
E-English
ES-European and
Slavic

G-German
ME-Middle Eastern
and South Asian
M-Native
Central/South
American/Mexican
AN-North
American/Alaska
Native
O-Other
P-Pacific Island
S-Spanish
Education
AT-Adult-College
Degree/Trng
Certificate

AC-Adult-College or
Advance Degree
AG-Adult-General
Education Diploma
A0-Adult-Grade 10
A1-Adult-Grade 11
A2-Adult-Grade 12
A9-Adult-Grade 9 or
less
AH-Adult-High School
Graduate
AA-Associates Degree
BS-Bachelors Degree
C1-Child Grade 1 - 6
M-Masters Degree
P-Preschool
U-Unknown

Y7-Youth Grade 7
thru 8
Y8-Youth Grade 9
thru 12
Relationship
A-Aunt
B-Brother
C-Custodial Parent
D-Daughter
DP-Dual Custodial
Parent
F-Father
FS-Former Spouse
FC-Foster Child
FP-Foster Parent
GC-Grandchild

GP-Grandparent
HH-Head of
Household
I-In-Law
M-Mother
N-Nephew
NI-Niece
O-other
P-Partner
SI-Sister
S-Son
SP-Spouse
SC-Stepchild
U-Uncle

Alabama
MOBILE HOME PRIORITY MEASURES LIST
(January 2016)

Weatherization
Assistance
Program

Weatherization measures must be installed in the order they are listed below. A measure of higher priority may not be skipped for
one of lower priority, see WPN 13-5 for additional information. Mobile homes with pitched, bowstring, and flat roofs; with vented and
unvented walls; lengthwise, and widthwise joists are common characteristics of typical mobile homes. If a mobile home does not fall
within these categories it is not considered typical and a house specific MHEA will be required. The cost associated with incidental
repairs should not exceed $500.00, if incidental repairs exceed the limit the unit must be evaluated with a MHEA Audit. Health and
Safety inspection and testing will be conducted and deficiencies corrected before the delivery of any weatherization services. If for
any reason a certain measure cannot be performed, the next immediate measure will be performed.

Priority
#1

Measure
Seal Ducts

Description and Comments

Seal duct system with mastic and fiberglass mesh tape.

Repair or replace duct boots.
Seal ends of trunk line.
Seal the furnace base, which is the plenum that connects the furnace to the duct system.

Cost for air sealing is limited by the amount of infiltration reduction. The following chart specifies
cost that may be charged for air sealing based on the primary fuel and CFM reduction.

#2

Air
Sealing/Infiltration
Reduction

#3

Roof Insulation

#4

#5

Wall Insulation

Belly Insulation
Programmable
Thermostat

Optional
Refrigerator
Replacement
PreApproved
Measures

General

NEAT
AUDIT
REQUIRED

Allowable with and

SIR of 1 or greater

Example: A Natural Gas home with a 1400 cfm reduction = $560.00 cost limit for air sealing
1400/100=14 14*$40.00=$560.00
Primary Space Heating Fuel
Price per 100 CFM Reduction
Heat Pump
$30.00
Natural Gas
$40.00
Propane
$50.00
Electric Resistance
$40.00

All air sealing work should be guided by use of the Blower Door.

Priority should be given to ductwork located in unconditioned spaces and air leakage at the
attic and floor planes of the home.

Seal plumbing, electrical, and HVAC penetrations through ceiling, flooring, & exterior
walls use proper materials for high-temperature surfaces.

Fill roof cavity with loose fiberglass insulation.

Air seal ceiling to prevent insulation from escaping the roof cavity.

Wall insulation is only cost effective for existing under-insulated exterior walls
Auditors should inspect all exterior walls for the presence of insulation.
If more than 2 inches of open cavity space is available walls should be insulated.
If less than 2 inches of open cavity space is available walls should not be insulated, in
such cases documentation must be provided.

Fill belly and wing cavities with loose fiberglass insulation.

Repair belly material and wing board as necessary.
Snug up belly material so that 8 to 10 inches of insulation is needed to fill the cavity.
Consider only insulating the belly if the wings are in good shape.

For central heating and/or cooling systems, setback thermostats can be cost effective if the
client is educated on the proper use of these devices.

Do not install if client has difficulty understanding the instructions.

Refrigerators may be replaced if:

Database shows existing unit is old/inefficient enough for replacement to be cost effective.

Metering proves it is cost effective to replace.

The following measures are considered generally cost-effective nationwide and are recommended to
be installed in all homes.

DHW Pipe Insulation

Faucet Aerators

DHW Tank Insulation

HVAC System Filters

Low-Flow Showerheads

Lighting Retrofits (CFL bulbs)

When replacing any of the following as an energy conservation measure, a MHEA Audit must be
used in lieu of the Priority Measures List. All measures must receive an SIR of 1 or greater.

DHW Replacement

HVAC Replacement
**When installing any of these as a Health and Safety measure, the MHEA Audit must be used
in lieu of the Priority Measures List. The individual Health and Safety measure will not require
an SIR of 1 or greater but will have to be included in the cumulative SIR for the package of
measures.

PRIORITY POINT WORKSHEET

APPLICANTS NAME: __________________________________________________

YES

1. If head of household is disabled

[10 Points]

2. If head of household is elderly (60 or over)

[10 Points]

3. Household with children under 18 years of age

[10 Points]

4. If one or more other members of the household is elderly

and/or disabled.

[05 Points]

NO

POINTS

5. If an eligible applicant has been on the waiting list for the period of one (1)
calendar year or more from the date of initial application. (These points may
only be applied one (1) time.)
[05 Points]

6. If total annual income of household is at or below 100% of poverty

guidelines.

[05 Points]

7. High Energy Consumer (utility bill $200.00 or more) or**

[05 Points]

8. LIHEAP Client

[05 Points]

TOTAL POINTS
** Applicants can receive priority points for being a high energy consumer or a LIHEAP client not both.

Alabama
SITE BUILT PRIORITY MEASURES LIST
(January 2016)

Weatherization
Assistance
Program

Weatherization measures must be installed in the order they are listed below. A measure of higher priority may not be skipped for one of lower
priority, see WPN 13-5 for additional information. Single-family dwellings ranging from 500 to 2,000 sq. ft., wood or masonry framed on slab, crawl
space, or pier foundation with unfinished and kneewall attics are eligible to be weatherized using the Priority Measures List. Dwellings that differ in
construction, condition, or energy use from those listed above will require the site-specific application of NEAT. The cost associated with incidental
repairs should not exceed $500.00, if incidental repairs exceed the limit the unit must be evaluated with a NEAT Audit. Health and Safety inspection
and testing will be conducted and deficiencies corrected before the delivery of any weatherization services. If for any reason a certain measure cannot
be performed, the next immediate measure will be performed.

Priority

Measure

Description and Comments

Cost for air sealing is limited by the amount of infiltration reduction. The following chart specifies
cost that may be charged for air sealing based on the primary fuel and CFM reduction.

#1

#2

Air
Sealing/Infiltration
Reduction

Attic Insulation

#3

Dense-Pack
Sidewall
Insulation

#4

Duct Insulation

#5

Floor Insulation
Programmable
Thermostat

Optional
Refrigerator
Replacement

Example: A Natural Gas home with a 1400 cfm reduction = $980.00 cost limit for air sealing
1400/100=14 14*$70.00=$980.00
Primary Space Heating Fuel
Price per 100 CFM Reduction
Electric Heat Pump
$66.00
Natural Gas
$70.00
Propane
$90.00

All air sealing work should be guided by use of the Blower Door.

Priority should be given to ductwork located in unconditioned spaces and air leakage at
the attic and floor planes of the home.

Seal plumbing, electrical, and HVAC penetrations through ceiling, flooring, & exterior
walls use proper materials for high-temperature surfaces.
All electrical circuits are to be checked first. Enclose exposed wires and connections in junction
boxes. Attic by-passes should be sealed prior to the installation of attic insulation.

Build dams for knob & tube or rewire all knob & tube circuits.

Attics insulated to R-19 or more will not receive additional insulation.

Attics insulated to less than R-19 should be insulated to R-30.

Attic access must be insulated to the equivalent R-value of the attic.

Wall insulation is only cost effective for existing uninsulated wood framed exterior walls.

Auditors should inspect all exterior walls for presence of existing insulation.

If no existing wall insulation is present, dense-pack all sidewall cavities with insulation.

If insulation is present, additional insulation should not be added.

Duct insulation should be installed in all homes where uninsulated duct work is located in
unconditioned spaces.

Uninsulated ducts in unconditioned attics should be insulated to R-8.

Uninsulated ducts in other unconditioned areas should be insulated to R-6.

Floor insulation is cost effective for existing uninsulated foundation spaces.

Auditors should evaluate all unconditioned foundation spaces for the presence of
existing insulation.

If insulation is present, floor insulation should not be added.

If insulation is not present, floor insulation should be added to R-19.

For central heating and/or cooling systems, setback thermostats can be cost effective if
the client is educated on the proper use of these devices.

Do not install if client has difficulty understanding the instructions.

Refrigerators may be replaced if:

Database shows existing unit is old/inefficient enough for replacement to be cost

effective.

Metering proves it is cost effective to replace.

The following measures are considered generally cost-effective nationwide and are recommended
to be installed in all homes.

PreApproved
Measures

General

NEAT
AUDIT
REQUIRED

Allowable with
and SIR of 1 or
greater

DHW Pipe Insulation

Faucet Aerators

DHW Tank Insulation

HVAC System Filters

Low-Flow Showerheads

Lighting Retrofits (CFL bulbs)

When replacing any of the following as an energy conservation measure, a NEAT Audit must be
used in lieu of the Priority Measures List. All measures must receive an SIR of 1 or greater.

DHW Replacement

HVAC Replacement
**When installing any of these as a Health and Safety measure, the NEAT Audit must be
used in lieu of the Priority Measures List. The individual Health and Safety measure will not
require an SIR of 1 or greater but will have to be included in the cumulative SIR for the
package of measures.

Energy Program Guidelines

for Weatherization
Community Action Partnership
of North Alabama, Inc.
1909 Central Parkway SW
Decatur, Alabama 35601
Phone: 256-260-3116
Fax: 256-260-4012

One of the main goals of our Energy Program is to improve the energy efficiency in
homes. By weatherizing a home we are able to focus on energy consumption and
related health and safety measures.
To qualify for our Energy Program (DOE) the households income must be at or
below 200% of the current poverty guideline. The Low Income Weatherization
Assistance Program (LIWAP) requires the households income to be at or below 150% of
the poverty guideline.
2016 POVERTY INCOME GUIDELINES
CONTIGUOUS STATES U.S. GRANTEES
EFFECTIVE January 25, 2016
Income Levels Size of Family
Threshold
150%
Unit
1
$11,880
$17,820
2
$16,020
$24,030
3
$20,160
$30,240
4
$24,300
$36,450
5
$28,440
$42,660
6
$32,580
$48,870
7
$36,730
$55,095
8
$40,890
$61,335

200%
$23,760
$32.040
$40,320
$48,600
$56,880
$65,160
$73,460
$81,780

All qualifying applicants will be placed on the waiting list and will be notified by mail.
Applicants are then assigned priority points according to the state regulated guidelines.
All applicants on the waiting list are selected according to their priority points within the
county in which they reside.

PLEASE PROVIDE COPIES OF THE FOLLOWING INFORMATION WHEN YOU APPLY

FOR WEATHERIZATION OR YOUR APPLICATION CANNOT BE PROCESSED:
1. Homeowners Photo I.D. Alabama Drivers License or Identification Card.
2. Social Security Cards - for all household members.
3. Proof of Income - for all household members for the previous twelve months.
Documents accepted include: check stubs, award letters, railroad retirement,
unemployment compensation, strike benefits from the union fund, workers
compensation, veterans payment, training stipends, alimony, military allotments,
private pensions, government employee pension (including military retirement

pay), regular insurance or annuity payments, dividends, interest, rental income,

royalties, periodic receipts from estates or trust, and gambling or lottery
winnings. Self-Certification: After all other avenues of documenting income
eligibility are exhausted, self-certification is allowable. A notarized statement,
signed by potential applicant and indicating that he/she has no other proof of
income is to remain with application.
4. Proof of Home Ownership - Documents accepted include: A copy of the deed
for a house. For mobile homes title or bill of sale. (chattel mortgage/mobile
home mortgage)
5. **** Weatherization assistance may also be provided to families or individuals

residing in rental/leased dwellings. Before weatherizing a rental/leased dwelling

an applicant must have their landlord or authorized agent complete a R ENTAL
R ELEASE FOR M specifying that the landlord or authorized agent agrees to pay
up to 50% of the total cost of all weatherization related goods and services.

6. 12 Month Energy Usage Statement - electric & gas.

7. Property Report Card obtained from the County Appraisers Office, this will
show the year the home was built. Mobile home owners will have this
information on their title.
Please note THIS IS NOT A HOME REMODELING PROGRAM and we will only
address measures that are related to the energy consumption of a home.
Listed below are some of the measures that the weatherization program may provide:
Weatherization Measures:
Sealing air openings around pipes
Caulking and weather stripping windows
Caulking and weather stripping exterior doors
Door sweeps
Repair or replace thresholds
Seal air passages around air conditioner units
Attic insulation (if applicable)
Compact fluorescent bulbs
Wrap water heaters (w/insulated water heater blankets)
Build attic access
Weatherstrip attic access
Mechanical venting

Health and Safety measures:

Replace un-vented gas heater
Carbon Monoxide detector
Smoke alarm
Fire extinguisher
Enclose Exposed Wires
Install Outlet Gasket Covers
Replace Hot Water Heaters
Lead Safe Work Practices