Wood Burning Conversion Application

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* 1. Please provide the information below

Homeowner's Name

Address

Address 2

City/Town

ZIP/Postal Code

Email Address

Phone Number (Mobile and Home)

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* 2. Is this your primary residence?

Yes

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* 3. Number of years at address

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* 4. How many people live in your home?

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* 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.

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* 6. (Required) Please provide your complete 2018 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

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

Yes

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

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* 9. Are you current on your mortgage payments?

Yes

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

Yes

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* 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

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* 12. Is your appliance a wood-burning stove or fireplace?

Wood-burning stove

Fireplace

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

Brand

Model

Serial Number

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* 14. How many times do you burn in your stove or fireplace each week?

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

Sole

Primary

Secondary

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* 16. Do you have a gas line installed in your home?

Yes

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* 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

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* 18. If you are unable to burn fires in your existing stove or fireplace for monitoring purposes, please explain why.

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

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* 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.

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* 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)

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* 1. Please provide the information below

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* 2. Is this your primary residence?

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* 3. Number of years at address

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* 4. How many people live in your home?

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* 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.

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* 6. (Required) Please provide your complete 2018 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.

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

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

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* 9. Are you current on your mortgage payments?

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

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.

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* 12. Is your appliance a wood-burning stove or fireplace?

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

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* 14. How many times do you burn in your stove or fireplace each week?

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

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* 16. Do you have a gas line installed in your home?

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* 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?

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* 18. If you are unable to burn fires in your existing stove or fireplace for monitoring purposes, please explain why.

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

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

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* 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)

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

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* 23. Upload additional files here

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* 24. Upload additional files here

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* 25. Type your name below to sign:

* 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.

* 6. (Required) Please provide your complete 2018 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.