Wood Stove Exchange 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. 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.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

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

Yes

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

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* 8. Are you current on your mortgage payments?

Yes

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

Yes

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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.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

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

Brand

Model

Serial Number

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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?

Sole

Primary

Secondary

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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:

I understand this application is for a grant to support the cost of replacing my wood burning appliance 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.

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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

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

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* 18. Upload additional files here

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.

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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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* 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:

* 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.