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* 1. Please provide the information below

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* 2. Number of years at address

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* 3. How many people live in your home?

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* 4. 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.

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* 5. Please provide copies of documentation of income. (For instance, the most recent income tax return, monthly social security statement, other retirement income statements, employment check stub and note on attached statements if it represents annual, monthly, twice‐monthly, bi‐weekly or weekly income.)
Additional files may be uploaded at the end of the form.

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* 6. Are you still making loan payments on your home?

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* 7. If yes, what is your monthly payment?

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* 8. Are you current on your mortgage payments?

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* 9. Are your Property Taxes and Homeowners Insurance included in your mortgage payment?

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* 10. 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.

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* 11. Current wood burning appliance brand, model and serial number (if applicable):

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* 12. Annual wood usage (how often do you use your stove or fireplace?)

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* 13. Is your appliance a sole, primary or secondary source of heat?

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* 14. Where did you learn about the Burn Smart program?

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* 15. Please check each box to affirm you understand the following:

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* 16. Please write a brief explanation of why you should be selected:

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* 17. Upload additional files here

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* 18. Upload additional files here

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* 19. Type your name below to sign:

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