JACKSON COUNTY

WEATHERIZATION ASSISTANCE PROGRAM

__________________________________________________________________

 

Dear Applicant:

 

Thank you for responding to the state funded Weatherization Assistance Program.  As manager, the Jackson County Community Development Department will seek every way in assisting you in determining your eligibility.

 

As you know, the purpose of this program is to weatherize homes to reduce energy consumption with priority given first to the elderly, second to the handicapped, and third to low-income families with children under the age of 12.

 

The application for this program is considered complete when all the following information has been submitted:

 

                1.    Complete the Initial Application

                2.    Show Proof of Income for each person who lives in the home

3.      Show Proof of Home Ownership or Secure a Landlord Agreement to weatherize      

       Dwelling and his/her Proof of Ownership

4.    Copies of photo ID/Social Security Cards.

5.    Most recent utility bill.

 

NOTE: all applications not containing the above needed information will not be processed.

 

Enclosed are the necessary forms needed to complete the three steps above.  Also enclosed is a Priority sheet we follow in weatherizing all homes.  Unfortunately, we are unable to do major repairs as our funds are limited.

 

We will weatherize as many homes as funding will allow and as quickly as possible.  A waiting list has been established and as your name comes up, you will be notified at that point as to the steps needed for your home to be weatherized.

 

Each step must be verified before eligibility determination.  Remember, the quicker you return these three (3) items, the sooner approval will be determined.  If you have any questions, feel free to contact this office at (850) 482-9083.

 

 

 

JACKSON COUNTY

WEATHERIZATION ASSISTANCE PROGRAM

______________________________________________________________________________

 

The following is a listing of documents required by the State of Florida for verification and qualification for the program.  Please make sure you have attached a copy of each one of these when you turn the application in.

 

PROOF OF INCOME

 

Income eligibility is based on the TOTAL FAMILY INCOME, and include all working members living in the home over the age of 18.

 

A) Use the enclosed forms in securing verification of income from

      * Social Security -----------------------------ATTACHMENT –A

      * AFDC/Food Stamps (HRS) --------------ATTACHMENT –B

 

B) You may show employment income verification by:

      * A payroll stub (current within the last three (3) months, showing your name and social security number)

      * A written statement on place of employment letterhead and signed by the employer.

 

PROOF OF HOME OWNERSHIP

 

To show proof of ownership, submit the enclosed ATTACHMENT –D form to the Tax Appraisers office for verification of the parcel identification number.

 

You may also show proof by providing one of the following items:

1.  Deed showing clients’ name

2.  Contract for deed

3.  Contract for purchasing mobile home

4.  Tax receipts showing clients’ name and property description

5.  Mobile home registration showing clients’ name and mobile home description

6.  Mobile home title.

 

IF YOU RENT

 

Secure the landlord’s written permission and their proof of ownership with ATTACHMENT –C.

 

Additional forms can be provided at your request.  If you need more space on this application, you may attach a separate piece of paper with the necessary information.

 

 

JACKSON COUNTY

WEATHERIZATION ASSISTANCE PROGRAM

APPLICATION

 

APPLICATION INFORMATION

Mr/Mrs: ___________________________________________________________________________________

                              LAST                                          FIRST                                       MIDDLE

ADDRESS: ________________________________________________________________________________

                      STREET/P.O. BOX NUMBER                         CITY                ZIP                   PHONE#

DATE OF BIRTH: ________         AGE: _____       SOCIAL SECURITY NUMBER _____________________

 

HOUSEHOLD MEMBERS INFORMATION

HOUSEHOLD MEMBERS

RELATIONSHIP

BIRTH DATE

PLACE OF EMPLOYMENT

MONTHLY WAGES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TOTAL NUMBER IN HOUSEHOLD: _________ TOTAL HANDICAPPED: ___________      TOTAL ELDERLY: ___________

 

HOUSEHOLD MEMBER INCOME LISTING

HOUSEHOLD MEMBERS

CLASSIFICATION

TYPE OF ASSISTANCE RECEIVING

MONTHLY AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CLASSIFICATION

TYPE OF ASSISTANCE

ELDERLY (OVER 60)                      HANDICAPPED 

SSI                                               AFDC                       FOOD STAMPS

INCOME                        AMERICAN INDIAN

RETIREMENT                         DISABILITY

OTHER: _______________________

 

 

 

JACKSON COUNTY

WEATHERIZATION ASSISTANCE PROGRAM

APPLICATION

DWELLING INFORMATION

DO YOU?: OWN ________                 RENT _______

 

IF YOU RENT THE HOME:    OWNERS NAME ________________________________________

PHONE___________________________

 

ADDRESS _____________________________CITY_______________________STATE_____________ZIP_______________

IS THE HOUSE?: SINGLE FAMILY ___________                 MULTI FAMILY _________                   DUPLEX _________

TYPE OF CONSTRUCTION OF HOME:      MOBILE HOME ______          WOOD _______          BLOCK ______          BRICK ______

DO YOU HAVE A FULL KITCHEN?:     YES ______        NO ________

WHAT ARE YOU MISSING? ______________________________________________________

WHAT TYPE OF SEPTIC SYSTEM DO YOU HAVE?: SEPTIC TANK _________       MUNICIPAL _________        NONE ________

WHAT TYPE OF WATER SYSTEM DO YOU HAVE?: PRIVATE WELL _________     MUNICIPAL __________      NONE ________

HAS THIS DWELLING EVER BEEN WEATHERIZED THROUGH THIS PROGRAM?:   YES_______         NO________

IF SO, INDICATE THE DATE: MONTH _________________     YEAR ___________

CONDITION OF DWELLING: GOOD ________     FAIR _________     POOR _________    HOW OLD IS YOUR HOME _________

IN YOUR ESTIMATION, WHAT TYPE OF WORK DOES YOUR HOME NEED:

_______________________________________________________________________________________________________________

 

_______________________________________________________________________________________________________________

 

_______________________________________________________________________________________________________________

 

_______________________________________________________________________________________________________________

 

_______________________________________________________________________________________________________________

 

_______________________________________________________________________________________________________________

 

APPLICANT CERTIFICATION

I hereby attest that the information appearing above is accurate to the best of my knowledge.  I understand that I have the right to file a written complaint or appeal the Jackson County Community Development Department.

 

 

___________________________________________________                                __________________   

                                     Client signature                                                                                            Date

 

 

 

 

 

JACKSON COUNTY

WEATHERIZATION ASSISTANCE PROGRAM

PROPERTY LOCATION FORM

 

PLEASE DRAW TO THE BEST OF YOUR ABILITY THE DIRECTIONS TO YOUR HOME STARTING ON HIGHWAY 90 (LAFAYETTE STREET).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE GIVE WRITTEN DIRECTIONS TO YOUR HOME STARTING ON HIGHWAY 90 (LAFAYETTE STREET).

 

 

 

 

 

 

 

 

 

 

 

JACKSON COUNTY

WEATHERIZATION ASSISTANCE PROGRAM

SOCIAL SECURITY VERIFICATION FORM–ATTACHMENT-A

 

TO: SOCIAL SECURITY ADMINISTRATION

 

Our client ___________________________________ whose address is ______________________________

 

______________________________ and social security number is ______________, has applied for our low-income families Home Weatherization Program.  Before consideration can be given by our office, documentation of the income that is received from this department is required.

 

 

Please provide our office with the date and total amount of the last payment received by our client.

 

 

DATE ____________________                         AMOUNT $_________________

 

 

Income verified by ____________________________________                                __________________

                                               Name & Tile                                                                             Date

 

APPLICANT PERMISSION TO RELEASE INCOME DOCUMENTATION

I hereby, give my permission for my income documentation to be released to the Jackson County Community Development Department in regard to my Weatherization application.

 

_________________________________________                                          ___________________

                    Client signature                                                                                         Date

 

 

 

 

JACKSON COUNTY

WEATHERIZATION ASSISTANCE PROGRAM

HRS–AFDC/FOOD STAMP VERIFICATION–ATTACHMENT-B

TO: HRS–AFDC/FOOD STAMP OFFICE

 

Our client: __________________________________ whose address is ________________________________

 

______________________and social security number is ____________________, has applied for our low-income families Home Weatherization Program.  Before consideration can be given by our office, documentation of the income received by your department is required.

 

Please provide our office with the date and total amount of benefits received for the last three (3) months.

 

AFDC: ____________           _____________

                 Amount                        Date

 

FOOD STAMPS: _______________         ___________

                                   Amount                        Date

 

Benefits verified by: ____________________________________         ________________

                                                  Name & Title                                                 Date

 

APPLICANT PERMISSION TO RELEASE BENEFIT DOCUMENTATION

I hereby, give permission for my benefit documentation to be released to the Jackson County Community Development Department in regard to my Weatherization application.

 

_________________________________________               _______________

                     Client signature                                                          Date

 

 

 

 

JACKSON COUNTY

WEATHERIZATION ASSISTANCE PROGRAM

LANDLORD REPAIR AGREEMENT–ATTACHMENT-C

TO: WEATHERIZATION COORDINATOR

 

I have been advised by my low-income tenant, __________________________________, residing at

 

______________________________________________, of their request to make weatherization repairs on the property listed above.

 

I give the Jackson County Community Development Department as managing agent for the Weatherization Program, my permission to make the necessary repairs providing there is no cost to me.  Furthermore, based on the foregoing, I hereby agree not to sell the property or increase the rent paid by my tenant occupying this property (Weatherization applicant) for a period of one year.

 

______________________________________________                    ________________

                    Landlord signature                                                                      Date

 

Current rent paid $_________________

 

 

 

JACKSON COUNTY

WEATHERIZATION ASSISTANCE PROGRAM

PROPERTY APPRAISER’S VERIFICATION–ATTACHMENT-D

Mr./Mrs./Ms. ________________________________________,

 

Physical address of property to be weatherized

____________________________________________________________

has applied for the benefits of our Home Weatherization Assistance Program for low-income families.  This is a state funded program and verification of ownership and primary residence is required before work can begin.

 

Please furnish parcel identification number _________________________________ as it appears on your tax records and verify with your signature.

 

_____________________________________                      ________________

County Property Appraisal Representative                                        Date

 

Please return this document to the Jackson County Community Development Department.