Energy

• *First Name:

• *Last Name:

• *Telephone:

• Mailing Address:

• Unit #:

• City:

• State:WA

• Zip Code:

• Email Address:

• Are you self-employed?
  If so, please use the notes section below to explain what type of business you have and what your average gross monthly income is.

  Yes No

• If you live in the upper county (Cle Elum, Roslyn, Ronald, etc.) are you willing and able to travel to Ellensburg for your appointment?

  Yes No

• What is the primary heat source in the home?

  Gas Electric Propane Oil Wood

• Who is your utility company?

  Puget Sound Energy (PSE)  Kittitas Public District (PUD)  City of Ellensburg

• Is anyone in the household over the age of 60?

  Yes No

• Is anyone in the household disabled?

  Yes No

• Do you currently have 24-hour/final shut-off notice and/or do you have less than 10 days left of your primary heat source (e.g. oil, propane, wood, etc.)?

  Yes No
  (24-Hour shut-off notices will be verified with the utility company prior to scheduling an appointment.)

• Notes/CommentsPlease let us know how you heard about the program:
  (Newspaper, Friend, DSHS, Food Bank, Flyer, Etc.)

Powered by Tectite FormMail