Wood Burning Conversion Application Question Title * 1. Please provide the information below Homeowner's Name Address Address 2 City/Town ZIP/Postal Code Email Address Phone Number (Mobile and Home) OK Question Title * 2. Is this your primary residence? Yes No OK Question Title * 3. Number of years at address OK Question Title * 4. How many people live in your home? OK Question Title * 5. What is the total annual, combined income before taxes for the home?You must include all HOUSEHOLD income for each person (18+) in the house unless a full-time student. OK Question Title * 6. (Required) Please provide your complete 2019 tax return as proof of income. If social security is your sole source of income, please provide us with your annual social security statement. Additional files may be uploaded at the end of the form. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File (Required) Please provide your complete 2019 tax return as proof of income. If social security is your sole source of income, please provide us with your annual social security statement. Additional files may be uploaded at the end of the form. OK Question Title * 7. Are you still making loan payments on your home? Yes No OK Question Title * 8. If yes, what is your monthly payment? OK Question Title * 9. Are you current on your mortgage payments? Yes No OK Question Title * 10. Are your Property Taxes and Homeowners Insurance included in your mortgage payment? Yes No OK Question Title * 11. (Required) Please provide a copy of your most recent property tax statement and proof of your homeowner’s insurance. Additional files may be uploaded at the end of the form. PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only. Choose File Choose File No file chosen Remove File (Required) Please provide a copy of your most recent property tax statement and proof of your homeowner’s insurance. Additional files may be uploaded at the end of the form. OK Question Title * 12. Is your appliance a wood-burning stove or fireplace? Wood-burning stove Fireplace OK Question Title * 13. Current wood burning appliance brand, model and serial number (if applicable): Brand Model Serial Number OK Question Title * 14. How many times do you burn in your stove or fireplace each week? OK Question Title * 15. Is your appliance a sole, primary or secondary source of heat? Sole Primary Secondary OK Question Title * 16. Do you have a gas line installed in your home? Yes No OK Question Title * 17. In order to qualify for the Burn Smart program, we will need to monitor the air quality difference before and after installation of a gas insert. Are you willing to allow us to temporarily place Purple Air monitors inside and outside of your home before and after the conversion? Yes No OK Question Title * 18. If you are unable to burn fires in your existing stove or fireplace for monitoring purposes, please explain why. OK Question Title * 19. Where did you learn about the Burn Smart program? OK Question Title * 20. Please check each box to affirm you understand the following: I understand this application is for a grant to support the cost of replacing my wood-burning stove/fireplace with a gas appliance to reduce emissions and improve air quality. I understand these funds are available to home owners, not real estate investors, and the home must be my primary residence. I understand that to qualify for this program, natural gas or propane service must already be in place at my home. I understand this application is for the replacement of an operating wood burning appliance, and the appliance will be removed from my home and destroyed or recycled. I understand this application is for a voucher to apply toward the costs of a new gas appliance to replace my current wood burning appliance, and I must pay the balance of the costs of the new appliance. I understand that construction and installation must meet all city and state building and safety codes. I understand that Burn Smart representatives may use photographs, videos and other recordings of Burn Smart projects to further promote the program. I hereby grant all right, title and interest in any photographs or video recordings taken of the work being performed on my home, for this purpose. I understand that the purpose of this program is to improve air quality in our communities and that I will be helping to create a better, cleaner future for Summit County. OK Question Title * 21. Are you willing to provide follow-up statements or a testimonial about the positive effects of switching to a gas-burning appliance after installation? (This may be up to a year following the conversion) Yes No OK Question Title * 22. Please write a brief explanation of why you should be selected: OK Question Title * 23. Upload additional files here DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Upload additional files here OK Question Title * 24. Upload additional files here DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only. Choose File Choose File No file chosen Remove File Upload additional files here OK Question Title * 25. Type your name below to sign: OK NEXT