Kansas Weatherization
Assistance Program Application


Welcome to the Kansas Weatherization Assistance Program Application. Please proceed to apply below.

Eligible households receive a comprehensive home energy audit to identify inefficiencies and health and safety concerns.

PLEASE NOTE: Upon submitting form, you will receive an email to digitally sign and complete the application and submit to the agency

VISIT US HERE if you'd like to first learn more about the program.

Kansas Weatherization
Assistance Program Application

Weatherization improves energy efficiency and lowers utility bills by ensuring your home holds in heat and air conditioning while keeping hot and cold air out. Eligible households receive a comprehensive home energy audit to identify inefficiencies and health and safety concerns. Each home is different, and based on a home's unique audit results, improvements may include:

  • Sealing of drafts and air leaks, caulking doors and windows, weather-stripping
  • Testing, cleaning, repair, or replacement of heating and cooling systems and water heater
  • Adding insulation to ceilings, walls, floors, and foundations
  • Lighting, refrigerator, and fan upgrades

All services and upgrades are provided free of charge by our certified energy auditors and network of professional crews and contractors.

Required materials and documents that applicants will need to complete a full application:

  • Income figures for all household members for the past 3 months (You will have the option to upload income documents)
  • Information about all individuals living in the home including name, birth date, and gender
  • Utility company names and account numbers
  • If applicable, your landlord's information and permission
  • PRINT LANDLORD PERMISSION FORM HERE
  • If applicable, a notarized Affidavit of No Income

Income-eligible homeowners and renters. Households that receive Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), or utility assistance from the Low Income Energy Assistance Program (LIEAP) are automatically income-eligible.

View income eligibility plus house condition eligibility

Types of acceptable income, what is needed for each

Affidavit of No Income: If your household has no income, you'll be required to upload a notarized copy of the Affidavit of No Income document linked below. Please get this document notarized ahead of starting this application.

Affidavit of No Income ›

Priority may be given to households that contain elderly persons, persons with disabilities, families with children, and those households that are classified as high energy users or high energy burdened.  (High energy users are households who's previous 12-month energy use exceeds 100 MCF of natural gas or 14,000 kWh for electricity, or 800 gallons of propane.)  High energy users/burdened households are those where the overall annual energy costs are equal to or greater than 15% of the household's annual income.  The same 12-month period for determining income eligibility and annual energy bills will be used when calculating burden.

If you'd like to learn more about LIEAP please visit https://www.dcf.ks.gov/services/ees/Pages/EnergyAssistance.aspx

Applicant Info

Please complete the following information for the main applicant.

Name*
Used in Documents to know what agency. (ECKAN = 100s | SCKEDD = 200s | NCRPC = 300s | CAI = 400s)
Street Address*
Mailing Address

Household Composition & Dwelling

My residence is on the market for sale.*
My house is scheduled for acquisition or clearance under a governmental agency?*
My residence is being foreclosed on or is at risk to be foreclosed on.*
Have you received utility assistance from the Low-Income Energy Assistance Program (LIEAP)?*
Do you believe you may be a high energy user/burdened?*

Landlord/ Owner Information

Do you have an already signed Weatherization landlord permission form?*
Please upload it here*
No File Chosen
File uploads may not work on some mobile devices.
Which of the following would you prefer?*
Landlord/ Owner Name*
Landlord/ Property/ Owner Authorized Agent*
Landlord/ Owner Address*

Current Home Conditions

Do you have a working heat source?*
Select all that apply*
Is your home air conditioned?*
Select all that apply*
Select all that apply

Household Income

Does your household have income*
No income received

Income includes any of the following:

Wages/Salary before deductions, net receipts from non-farm or farm self-employment, SSI, Railroad retirement, unemployment, strike benefits from union funds, worker's comp, veteran's payments, alimony, dividends and/or interest, net rental income and net royalties, periodic receipts from estates or trusts, and net gambling or lottery winnings.

Household Member 1 (Main Applicant)

Full Name*
DOB*
Disabled?*
Health insurance

Income

Check all income types that apply & ENTER AVERAGE MONTHLY GROSS AMOUNT (Before taxes).

Select all income types this member receives - 1*
$
Wages
$
Self-Employment
$
Social Security
$
TANF/TAF
$
Spousal Support
$
Pension
$
VA Service Pension
$
SSI
$
SSDI
$
Unemployment Insurance
$
Worker's Compensation
$
VA Disability Compensation
$
Private Disability Insurance
$
Other - please define
No income received
$

Household Member 2

Full Name*
DOB*
Disabled?*

Income

Check all income types that apply & ENTER AVERAGE MONTHLY GROSS AMOUNT (Before taxes).

Select all income types this member receives - 2*
$
Wages
$
Self-Employment
$
Social Security
$
TANF/TAF
$
Spousal Support
$
Pension
$
VA Service Pension
$
SSI
$
SSDI
$
Unemployment Insurance
$
Worker's Compensation
$
VA Disability Compensation
$
Private Disability Insurance
$
Other - please define
No income received
$

Household Member 3

Full Name*
DOB*
Disabled?*

Income

Check all income types that apply & ENTER AVERAGE MONTHLY GROSS AMOUNT (Before taxes).

Select all income types this member receives - 3*
$
Wages
$
Self-Employment
$
Social Security
$
TANF/TAF
$
Spousal Support
$
Pension
$
VA Service Pension
$
SSI
$
SSDI
$
Unemployment Insurance
$
Worker's Compensation
$
VA Disability Compensation
$
Private Disability Insurance
$
Other - please define
No income received
$

Household Member 4

Full Name*
DOB*
Disabled?*

Income

Check all income types that apply & ENTER AVERAGE MONTHLY GROSS AMOUNT (Before taxes).

Select all income types this member receives - 4*
$
Wages
$
Self-Employment
$
Social Security
$
TANF/TAF
$
Spousal Support
$
Pension
$
VA Service Pension
$
SSI
$
SSDI
$
Unemployment Insurance
$
Worker's Compensation
$
VA Disability Compensation
$
Private Disability Insurance
$
Other - please define
No income received
$

Household Member 5

Full Name*
DOB*
Disabled?*

Income

Check all income types that apply & ENTER AVERAGE MONTHLY GROSS AMOUNT (Before taxes).

Select all income types this member receives - 5*
$
Wages
$
Self-Employment
$
Social Security
$
TANF/TAF
$
Spousal Support
$
Pension
$
VA Service Pension
$
SSI
$
SSDI
$
Unemployment Insurance
$
Worker's Compensation
$
VA Disability Compensation
$
Private Disability Insurance
$
Other - please define
No income received
$

Household Member 6

Full Name*
DOB*
Disabled?*

Income

Check all income types that apply & ENTER AVERAGE MONTHLY GROSS AMOUNT (Before taxes).

Select all income types this member receives - 6*
$
Wages
$
Self-Employment
$
Social Security
$
TANF/TAF
$
Spousal Support
$
Pension
$
VA Service Pension
$
SSI
$
SSDI
$
Unemployment Insurance
$
Worker's Compensation
$
VA Disability Compensation
$
Private Disability Insurance
$
Other - please define
No income received
$

Income Documentation

Would you like to upload any income documentation now?*

Affidavit of No Income

You selected your household has no income. Please upload a notarized copy of the Affidavit of No Income document.

Affidavit of No Income*
No File Chosen
File uploads may not work on some mobile devices.
Do you receive utility assistance from the Low Income Energy Assistance Program (LIEAP)?
No File Chosen
File uploads may not work on some mobile devices.
If yes, please upload your benefit letter, if available.

Use the fields below to attach any income documentation from the last three (3) months.

File 1
No File Chosen
File uploads may not work on some mobile devices.
File 2
No File Chosen
File uploads may not work on some mobile devices.
File 3
No File Chosen
File uploads may not work on some mobile devices.
File 4
No File Chosen
File uploads may not work on some mobile devices.
File 5
No File Chosen
File uploads may not work on some mobile devices.
File 6
No File Chosen
File uploads may not work on some mobile devices.
Do you receive utility assistance from the Low Income Energy Assistance Program (LIEAP)?
No File Chosen
File uploads may not work on some mobile devices.
If yes, please upload your benefit letter, if available.

Agreements

Permission to Drill

Permission for holes to be drilled in all the walls of my home (property) for installing sidewall insulation, and I understand that it will be my responsibility to paint the plugs used to fill these holes.*

Attestation & Understanding

I attest that the information: 

1) was provided voluntarily &
2) it is correct & complete. 

I understand that: 

1) the information will be kept confidential pursuant to the Privacy Act of 1974, as amended, but may be made known to other persons in pursuit of eligibility determination, funder reporting, & central data system reporting; &
2) any false statements could result in the denial of services.


Eligibility Certification

"I certify that there is at least one United States citizen or Qualified Alien who resides at the address listed on this application. Qualified Alien is defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996."


Weatherization Walk Away Policy

Weatherization staff is authorized to postpone or deny services to units under these circumstances.

Health & Safety:

  1. Unsanitary conditions where health of staff or contractor(s) would be placed in jeopardy
  2. Threat of violence or personal safety to staff or contractor(s) is in question
  3. Household member has a health condition which could be aggravated by weatherization
  4. Mold is found or excessive moisture conditions are present
  5. Source pollutants are found which would be aggravated by weatherization (i.e. moisture, friable asbestos, or radon)

Effectiveness:

  1. Remodeling or rehabilitation is planned or in progress
  2. Condition of dwelling is too degraded for weatherization to be effective (i.e-Major roof, foundation, or structural issues)
  3. Home is condemned or scheduled for demolition
  4. Client does not cooperate with weatherization personnel and either refuses entry, inspection, or measures selected by audit.

Once the agency has received your application and verified your income to determine eligibility, you are placed on a waiting list to receive a whole house energy audit inspection. When it is your turn, an inspector will contact you to set up a time for your inspection. The inspector will visit your home to gather the necessary information which must be entered into a computer program approved by the U.S. Department of Energy and the State of Kansas. This program provides the weatherization agency with a list of approved measures designed to reduce the energy consumption of your home. Each house is inspected in a similar manner and input in the audit software in a similar manner. However, due to the inherent differences in each building structure, the energy audit software may approve different measures for each house. After inspection, an appointment is then set for an agency crew or contractor to arrive to perform the work that has been approved for your home. Before any work is started, the crew supervisor will go over the list of work items with the homeowner. If there are no objections, the crew will proceed with the work. In cases where the homeowner objects to having any work item performed, the crew supervisor will contact the project inspector to discuss the objection before any work is started. If the housing inspector determines that the item objected is required for your health and safety, then we will be unable to do any of the items.

The services provided to you through the Kansas Weatherization Assistance Program are intended solely to reduce the energy consumption needs of your household. The weatherization agency receives a limited amount of money, and the Weatherization program regulations and guidelines limit the use of grant funds to specific approved measures which have been shown to reduce energy consumption. The work is performed by the agency staff or subcontractors who have received extensive training and experience in specific weatherization techniques. Please be advised that all weatherization work items are not intended to enhance or improve the appearance of the home. If my application is approved, I authorize the weatherization of my home to be completed by this program and will provide reasonable access to my property as required by weatherization personnel. If I disallow reasonable access to my home, I understand that my application will be deferred, and any work already completed will not be warrantied.

By signing below, I certify that I have read all information contained in this application and understand my rights and responsibilities as a client under the Kansas Weatherization Assistance Program. I also certify that the information given by me in this application is a true and accurate representation to the best of my knowledge. By signing this application, I understand that I may be civilly and/or criminally liable under Federal and State law for making any false or fraudulent representations. I also understand that any person that applies for the Kansas Weatherization Assistance Program has the right to appeal any denial, delay, or limitation of service under the grant program. Appeals must be sent in writing to the weatherization agency in your area.

Date/Time*
Use your mouse or finger to draw your signature above

Fuel Release Form

Heating Fuel Supplier

Name on the utility account

Electric Supplier

Name on the utility account

Fuel Release

This release shall apply to the above energy providers and any subsequent energy provider(s) formed through merger or acquisition therewith.

I hereby authorize the above energy providers to release information on my fuel bills to the following agencies: Kansas Weatherization Assistance Program, Low Income Home Energy Assistance Program.

I understand that this information will be used only to provide data for the above-named agencies, and no information obtained through this release shall be made public in such a manner that the dwelling or occupants can be identified.

This release shall apply for 3 years following the date of its execution.

Pre-Inspection Process & Client Interview

The following questions are to help the Weatherization Program better understand your home and what potential needs it may have. Please complete this form to the best of your knowledge.

Type of structure*
Foundation type*
Does the roof leak?*
Heating system*
Type of fuel*
Do you air condition in summer?*
Does moisture, frost, or ice collect on the window glass?*
Has foundation seepage, damp or wet basement or crawlspace ever been a problem?*

Questionnaire

Does your home have broken glass in windows and doors?*
Is the outside of your home free of debris so that a contractor could work on your home?*
Is the access to windows, doors, attic etc. free on the inside of your home?*
Are you in the process of remodeling or plan to remodel any portion of your home in the near future?*
Are any part of your ceilings, walls or floors incomplete or in need of repair?*
Do you have any broken or leaking water or sewer line?*
Does water leak/stand in the basement/crawlspace?*
If mobile home – is the underbelly free of debris and/or standing water?*
My residence is at‐risk for demolition and/or unsafe/unfit designation.*
My residence is currently for sale or will be sold in the next 12 months.*
The house is currently unoccupied or being currently vacated.*
My utilities are currently disconnected or are at‐risk for immediate disconnection.*

Household Income

$
Wages
$
Self-Employment
$
Social Security
$
TANF/TAF
$
Spousal Support
$
Pension
$
VA Service Pension
$
SSI
$
SSDI
$
Unemployment Insurance
$
Worker's Compensation
$
VA Disability Compensation
$
Private Disability Insurance
$
Other - please define
$
ALL Household Income
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