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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. 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. 
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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?

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* 11. 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:

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