Weatherization Application : Devils Lake : Programs by Region : What We Do : Community Action Partnership of North Dakota

First & Last Name (Required)

Social Security # (Required)

Birth Date

Month

/

Day

/

Year

County (Required)

Gender (Required)

Disabled?

Veteran?

What is Your Race?

Hispanic?

Email Address (Required)

Phone Number (Required)

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Directions to Home (Required)

Receive Food Stamps?

Receive Fuel Assistance? (Required)

Highest Level of Education Completed

Type of Health Coverage

Household Type

Housing Type (Required)

Housing Status (Required)

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Household Income (check all that apply)

Amount Per Month (Required)

Heat (Required)

Electricity (Required)

Source(s) of Heat

Total Number of people in your household (Required)

How long have you lived in this home (Required)

What year was your home built (Required)

Has your home been weatherized by us before (Required)

Do you have any heath problems? (Required)

(Required)