1.What county do you live in?

Daviess

Knox

Greene

Sullivan

2.Did you apply for Energy Assistance last year?

Yes

No

3.If you are a NEW applicant, how did you hear about the Energy Assistance program? (Check all that apply)

Advertisement - Flyer, newspaper, radio, social media, etc.

Another person

Pace Website

Referred by a community partner/trustee. Please list below:

Additional information:

4.The application packet included a checklist which listed all the required documentation to be submitted. Was this form easy to understand?

Yes

No

5.Which of these do you do to conserve energy? (Check all that apply)

Replaced light bulbs with energy saving bulbs

Washing clothes in cold water

Changed the furnace filter

Added window or door insulation

Opened/Uncovered ALL air vents

Opened/Closed curtains to heat/cool home

Installed a programable thermostat

Adjusted thermostat

Purchased an Energy Star appliance or item

Clean the dryer vent after each load

Wash full loads of laundry

Use smaller kitchen appliances when possible

Unplug small appliances when not in use

Airdry clothes

Turn off lights when not needed

6.Were you treated with respect by Pace staff?

5 - Highly Satisfied

4

3

2

1 - Very Dissatisfied

7.Did you require assistance completing your application

Yes

No

8.Additional Comments or suggestions: