Property / Home Address *
Home Owner Name *
First
Last
Home Owner Name (co-owner)
First
Last
Phone Number of Home Owner *
Email of Homeowner *
Names of Other Adult Wage Earners in Household
Number of Dependents Living in Household *
Family members under the age of 18.
Total Annual Household Income *
Include earnings from payroll, dividends, PFDs, etc. Do not use any periods, commas or dollar signs.
Total Value of Financial Assets *
Assets can include dividends, retirement account, pensions, deferred compensation accounts, trusts, etc. Do not use any periods, commas or dollar signs.
Current Heating Methods *
List all home heat sources (oil boiler, oil stove, propane, baseboard electric, wood, pellet, other)
Size of home *
Provide an approximate total square footage of your heated living spaces.
How many rooms are your home? *
3-4
5-6
7-8
9+
A room is a space that you currently use and that is heated on a regular basis.
Energy Efficiency Estimate


	Selected Value: 0
Try to estimate the efficiency of your home: tight, leaky, well or poorly insulated, single pane windows, double pane windows, drafty, well insulated, etc. 
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