AACOG Weatherization Program Pre-Application Form

Please provide the following contact information:

Please complete the following Home Information Survey:

HOME INFORMATION SURVEY

1. Do you live in a:

wood frame house
brick house
mobile home (trailer)
apartment house

2. Does your roof leak? yes     no

3. Do your ceilings have large holes or cracks? yes     no

4. Do your ceilings have insulation? yes     no

5. Does your home have a good foundation? yes     no

6. Are there any holes in your floors? yes     no

7. Do your walls have large holes or cracks?  yes     no

8. Do your walls have insulation? yes     no

9. How many windows does your home have?

wood     aluminum

Are your windows in good condition? yes     no

10. How many doors (to outside) does your home have?

Are your doors in good condition? yes     no

7. What do use to heat your home in the winter?

space heater    How many?

electric heater  How many?

8. What do you use to cool your house in the summer?

window unit    How many?

central unit   How many?

9. In your opinion, what do you think your home needs the most?