SmartGrid Interest Form
Resident/Owner Information

Contact Information
*Required fields
Resident
*Building Type:
*Last Name: *First Name:
*Address 1:
Address 2:
*City: *State: *Zipcode:
Home phone: Work phone:
*Internet access? Home Work Library Mobile
E-mail:
Best contact method: Home phone Work phone E-mail U.S.P.S.
Best contact time:
Owner Same as Resident
*Do you own or rent your home?
Last name: First name:
Address 1:
Address 2:
City: State: Zipcode:
Home phone: Work phone:

Household, Demographic & Other Information

Household
Number of adults in household:
Number of children in household:
(under 18 yrs)
Is your income less than $14,180?
Household income:
Demographic
Age: Gender:
Marital Status:
Race:
Hispanic Origin:
Employment
Are you employed?
Employer:
Other
Neighborhood organization participant?
*Previous home weatherization (1994+)?
*What type of air conditioner do you have?