Weatherization Manual Policies and Procedures Supporting Documents for United States Department of Energy (doe) United States Department of Health and Human Services (hhs) Bonneville Power Administration



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Sample Weatherization Program

  • Utility Information Release Waiver


  • Section A: Applicant Information

  • Primary Applicant: 

  • (Last Name) (First Name) (Middle Initial)



  • Mailing Address:

  • Mailing City, State, ZIP:

  • Phone: ( )

  • Residence Address:

  • Residence City, State, Zip:

  • Name on utility account if different from applicant:



  • Section B: Utility Information

  • Utility Service Provider (as applicable):



  • Electric: Acct. #

  • Natural Gas: Acct. #

  • Propane: Acct. #

  • Oil: Acct. #

  • Wood: Acct. #

  • Coal: Acct. #



  • Primary Heat Source: Secondary Heat Source:

  • (Electric, Natural Gas, Propane, Oil, Wood, Coal)



  • I certify that the above information is accurate to the best of my knowledge. I give the above listed utility service providers permission to release my account information, including both consumption and expenditure data, to this agency or the Washington State Department of Commerce for current and future data analysis.

  • Applicant Signature: Date:

  • Page 1 of 3
  • List of Qualified Alien Documents




  • The following is a list of documents acceptable to prove a clients Qualified Alien status.  

  • Certain USCIS documents can be viewed online at: http://www.ncosc.net/Foreign_Nationals/Travel_Doc_Identification.pdf

    1. IMMIGRATION STATUS

    1. VERIFICATION DOCUMENT ( USCIS U.S. Citizenship and Immigration Services U.S. Citizenship and Immigration ServicesFORMS)

    1. Legal Permanent Resident - a person who has been granted lawful permanent residence in the United States

    • I-551 (referred to as green card), or

    • I-94 annotated with a temporary I-551 stamp (for recent arrivals or aliens who have applied for a replacement I-551)

    1. Refugee - Under United States law, a refugee is someone who:

    • Is located outside of the United States

    • Is of special humanitarian concern to the United States

    • Demonstrates that they were persecuted or fear persecution due to race, religion, nationality, political opinion, or membership in a particular social group
      Is not firmly resettled in another country

    • Is admissible to the United States

    1. A refugee does not include anyone who ordered, incited, assisted, or otherwise participated in the persecution of any person on account of race, religion, nationality, membership in a particular social group, or political opinion.

    • I-94 stamped showing admission under

    • section 207 of the INA Immigration & Nationality Act and date of entry to the U.S. United States, or

    • I-688B annotated 274a.12(a)(3), or

    • I-766 annotated A3, or,

    • I-571



    1. (Refugees usually adjust to LPR status after 12 months in the U.S. United States., However, they are still considered refugee for eligibility purposes when they have a I-551 with a code of RE-6, RE-7, RE-8, or RE-9)

    1. Special Immigrants - A special immigrant is a person who qualifies for a green card (permanent residence) under the United States Citizenship and Immigration Services (USCIS) special immigrant program.

    • I-94 or passport stamped with an "S" category

    1. Asylee - An alien in the United States or at a port of entry who is found to be unable or unwilling to return to his or her country of nationality, or to seek the protection of that country because of persecution or a well-founded fear of persecution. Persecution or the fear thereof must be based on the alien’s race, religion, nationality, membership in a particular social group, or political opinion. For persons with no nationality, the country of nationality is considered to be the country in which the alien last habitually resided. Asylees are eligible to adjust to lawful permanent resident status after one year of continuous presence in the United States.

    • I-94 stamped showing grant of asylum under section 208 and date of entry; or

    • A grant letter from the Asylum Office of the USCIS U.S. Citizenship and Immigration Services; or

    • I-688B annotated 274a.12(a)(5); or

    • I-766 annotated A5; or

    • Court order of an immigration judge showing asylum granted under section 208.

    1. Parolee

    • I-94 annotated with stamp showing grant of parole under 212(d)(5) and a date showing granting of parole for at least 1 year.

    1. Deportation Withheld

    • Order of an immigration judge showing deportation withheld under section 243(h) and date of grant; or

    • I-688B annotated 274a.12(a)(10); or

    • I-766 annotated A10.

    1. Conditional Entrant

    • I-94 with stamp showing admission under 203(a)(7), refugee-conditional entry, or

    • I-688B annotated 274a.12(a)(3)

    • I-766 annotated A3

    1. Battered Spouse or Child of U.S. United States Citizen or Permanent Legal Resident

    • Approved or pending I-130 or I-360 petition showing a prima facie case that he or she is protected under the Violence Against Women Act, and

    • Verification that the individual responsible for the battery or cruelty is no longer living in the household of the victim. 

    1. Cuban or Haitian Entrants

    • I-94 with stamp showing parole as Cuban/Haitian Entrant under section 212(d)(5) of the INA Immigration & Nationality Act

    • Form I-551 with code CU6, CU7, or CH6

    • Foreign passport containing an unexpired temporary I-551 stamp with the code CU6 or CU7

    1. U.S. United States  Military Veteran, Active Duty Military

    2. (includes spouse and unmarried dependent children under 21)

    • Green Form DD-2 marked ACTIVE, or

    • A current order showing the individual is on full-time duty in the U.S. United States Army, Navy, Air Force, Marine Corps, or Coast Guard (Reserves are not considered active duty).

    • DD-214 indicating honorable discharge, or

    • Discharge papers indicating honorable discharge

    1. Victims Of Trafficking

    2. (includes certain eligible immediate family members holding a derivative T-Visa)

    • Letter of certification from the Office of Refugee Resettlement (ORR Office of Refugee Resettlement.)  The caseworker must verify the validity of this letter and notify ORR Office of Refugee Resettlement  of the benefits for which the individual has applied by calling the toll-free trafficking verification line at 1-866-401-5510.

    • Form I-797a indicating Class T-1 Visa.

    • Form I-797a indicating T-2 (spouse), T-3 (child), T-4 (parent) or T-5 (unmarried sibling under age18 years on the date such alien’s T visa application was filed), known as a Derivative Visa.

    1. Note: T status is valid for 3 years from date of approval and is not renewable. However, the individual may adjust to lawful permanent resident status within the 90-day period immediately preceding the expiration of T status.

    1. American Indian Born In Canada

    • Birth or baptismal certificate issued on a reservation;

    • Tribal records;

    • Letter from the Canadian Department of Indian Affairs, or

    • School records



  • Page 1 of 3


  • Weatherization Program

  • Property Owner/Agency Agreement


  • [ ] Single Family

  • [ ] Duplex

  • [ ] Triplex

  • [ ] 4-Plex



  • I, certify that I am the owner/authorized agent

  • (Owner/Agent)

  • for the property located at presently rented by:

  • (Address)



  • Tenant(s) Tenant Rent Contract Rent

  • (Subsidized

  • Housing Only)

  • 1.

  • 2.

  • 3.

  • 4.



  • I authorize______________________________________________________________

  • (Agency)

  • to make the following weatherization repairs and improvements with the understanding that I will make a cash contribution in the amount of $







  • Page 2 of 3

  • I hereby release and pledge to hold harmless the above-named agency and its staff from any liability in connection with the work listed above.

  • In consideration of the weatherization work to be performed, the parties agree:

    1. "Rent" is defined as the tenant’s monthly payment to the owner (non-subsidized housing) or the contract rent (subsidized housing).

    2. That the rent shall not be raised at any time because of increased value of the rental unit(s) due solely to weatherization assistance.

    3. That from the effective date of this agreement, and during a period extending through one (1) year following the date of completion of weatherization work, the amount of rent at all rental units being weatherized will not be raised for any reason. That at the end of this period the rent shall not be raised for an additional period of one (1) year, except to reflect tenants' prorated share of the following expenses actually incurred and documented by the owner: (i) actual increases in property taxes; (ii) actual cost of amortizing improvements to the property (other than weatherization), which are accomplished on or after the date of this agreement and which directly benefit tenants; or (iii) actual increases in expenses of maintaining and operating the property.

    4. The provisions of paragraph 3 may be waived by the agency in writing if, and only if, the premises are leased under a state or federal rent subsidy program which restricts the amount of rent the owner may charge, in which case the actual contract rent charged by the owner shall conform to the standards of the rent subsidy program.

    5. That from the effective date of this agreement, and during a period extending through three (3) years following the date of completion of weatherization work performed, the owner will not evict, terminate, or institute any court action for possession against any tenant or successive tenant, except for good cause pursuant to the Unlawful Detainer Statute, RCW 59.12.030(3)-(5) (e.g. nonpayment of rent, committing waste, maintaining a nuisance) (http://apps.leg.wa.gov/RCW).

    6. That in the event the owner sells the premises within three (3) years after weatherization work is completed, the owner will comply with one of the two following conditions:

      1. The owner shall repay the agency at the date of sale an amount equal to the percentage of the three (3) year/month period remaining, times the full value of the material and labor as documented by the agency work records, except if sold to low-income tenants; or

      2. The owner shall obtain, in writing prior to sale, the purchaser's agreement to assume the owner's obligations under this agreement.

    1. The owner shall immediately upon entering into a non-contingent agreement of sale of the premises, so inform both the agency and the tenants, by written notice.

    2. Page 3 of 3

    1. That the present tenants, or any successor tenants during the term of this agreement, are the intended beneficiaries of this agreement and shall have a right of enforcement.

    2. That for breach of this agreement, damages, where not otherwise specified, may be awarded in accordance with applicable law. The prevailing party in any suit to enforce 0this agreement shall be entitled to recover his costs and a reasonable attorney's fee.

    3. That the agency shall provide a copy of this agreement and a synopsis explaining its terms to the tenants. That the owner shall provide a synopsis explaining the terms of this agreement to subsequent tenants of the above rental units, or to the new and subsequent occupants of rental units vacant on the effective date of this agreement.

    4. That the terms of this agreement are incorporated into any other lease or agreement between owner and tenants, and between owner and any successor tenants during terms of this agreement, and if there is any conflict between the provisions of this agreement and provisions of such other lease or agreement, the provisions of this agreement shall govern. With the exception of provisions outlined above, all provisions of the Washington State Landlord/Tenant Act (RCW 59.18) (http://apps.leg.wa.gov/RCW) and the Washington State Manufactured/Mobile Home Landlord/Tenant Act (RCW 59.20) (http://apps.leg.wa.gov/RCW) shall apply to the owner(s) and tenant(s).

    5. That provisions of this agreement are severable. If any provision of this agreement is found invalid, such finding shall not affect the validity of this agreement as a whole, or any part or provision hereof other than the provision so found to be invalid.

    6. Failure of the agency to enforce the agreement upon breach by the owner shall not be construed as a waiver of the agency's right to enforce the agreement.



    1. Signed: Date:

    2. (Owner/Authorized Agent)

    3. Address: Phone:





    4. Approved by: Date:

    5. (Agency Representative)


    6. Page 1 of 3

    7. Weatherization Program

    8. Property Owner/Agency Agreement for

    9. Multi-Family Buildings




    10. I, , certify that I am the owner/authorized agent

    11. (Owner/Agent)

    12. for the property located at



    13. I authorize the



    14. (Agency)

    15. to make weatherization repairs and improvements as determined by an energy audit of the building. I will make cash contributions in the amount of $ .

    16. I hereby release and pledge to hold harmless the above-named agency and its staff from any liability in connection with the weatherization work.

    17. In consideration of the weatherization work to be performed, parties agree:

    1. "Rent” is defined as the tenant’s monthly payment to the owner (non-subsidized housing) or the contract rent (subsidized housing).

    2. That the rent shall not be raised at any time because of any increase in the value of the rental units due solely to weatherization assistance.

    3. That the owner/agent will submit a current rent schedule prior to completion of weatherization work upon request of the agency.

    1. That during a period extending through one (1) year beginning on the date of agency certified completion of weatherization work, the amount of rent, as established by the rent schedule submitted, will not be raised for any reason for any building tenant.

    1. That at the end of this one-year period, rent shall not be raised for an additional period of one (1) year, except to reflect the tenants' prorated share of the following expenses actually incurred and documented by the owner/agent:

      1. Actual increases in property taxes.
    1. Page 2 of 3




      1. Actual costs of amortizing improvements to the property (other than weatherization), which are accomplished on or after the date of this agreement and which directly benefit the tenants.

      2. Actual increases in expenses of maintaining and operating the property.

    1. The provisions of paragraph 4 may be waived by the agency in writing if, and only if, the premises are leased under a state or federal rent subsidy program which restricts the amount of rent the owner may charge, in which case, the actual contract rent charged by the owner shall conform to the standards of the rent subsidy program.

    2. That from the effective date of this agreement, and during a period extending through three (3) years following the date of completion of the weatherization work performed, the owner will not evict, terminate, or institute any court action for possession against any tenant or successive tenant, except for good cause pursuant to the Unlawful Detainer Statute, RCW 59.12.030(3)-(5) (e.g. nonpayment of rent, committing waste, maintaining a nuisance) (http://apps.leg.wa.gov/RCW).

    3. That in the event the agency determines that the owner\agent has violated the terms of this agreement, the owner\agent shall repay the agency the full value of materials and labor as documented by agency work records.

    4. That in the event the owner sells the premises within three (3) years after weatherization work is completed, the owner will comply with one of the two following conditions:

      1. The owner shall repay the agency at the date of sale an amount equal to the percentage of the three (3) year/month period remaining, times the full value of the material and labor as documented by agency work records, except if sold to low-income tenants.

      2. The owner shall obtain in writing prior to sale the purchaser's agreement to assume the owner's obligations under this agreement.

    1. The owner shall immediately upon entering into a non-contingent agreement of sale of premises, so inform both the agency and tenants by written notice.

    1. That present tenants, or any successive tenants during the term of this agreement, are the intended beneficiaries of this agreement and shall have a right of enforcement.

    2. That for breach of this agreement, damages, where not otherwise specified, may be awarded in accordance with applicable law. The prevailing party in any suit to enforce this agreement shall be entitled to recover costs and a reasonable attorney's fee.



    1. Page 3 of 3

    1. That the agency shall provide a copy of this agreement and a synopsis explaining its terms to the tenants. That the owner shall provide a synopsis explaining the terms of this agreement to subsequent tenants of the above rental units, or to the new and subsequent occupants of rental units vacant on the effective date of this agreement.

    2. That the terms of this agreement are incorporated into any other lease or agreement between owner and tenants, and between owner and any successor tenants during the terms of this agreement, and if there is any conflict between the provisions of this agreement and the provisions of such other lease or agreement, the provisions of this agreement shall govern. With the exception of the provisions outlined above, all provisions of the Washington State Landlord/Tenant Act (RCW 59.18) (http://apps.leg.wa.gov/RCW) and the Washington State Manufactured/Mobile Home Landlord/Tenant Act (RCW 59.20) (http://apps.leg.wa.gov/RCW) shall apply to owner(s) and tenant(s).

    3. That the provisions of this agreement are severable. If any provision of this agreement is found invalid, such finding shall not affect the validity of this agreement as a whole, or any part or provision hereof other than the provision so found to be invalid.

    4. Failure of the agency to enforce the agreement upon breach by the owner shall not be construed as a waiver of the agency's right to enforce the agreement.



    1. Signed: Date:

    2. (Owner/Authorized Agent)

    3. Address: Phone:



    4. Approved by: Date:

    5. (Agency Representative)

    1. AReason for the Agreement

    2. The Agreement ensures the tenant receives the full benefit of the energy-saving measures installed.







    3. Saving energy is everyone’s responsibility!



    4. Space and water heating are the two largest residential energy users.



    5. To save energy:



    • Water heaters should be set at 120 degrees (120o Fahrenheit).



    • Furnaces and other heating systems should be checked annually to ensure efficient operation.



    • Trees and vegetation that are touching or hanging over a building can create moisture problems that will damage the structure over time. Be sure to trim trees and shrubs and keep leaves, moss, and other debris off the roof and out of gutters and downspouts.

    1. Everyone is a winner in a weatherization partnership!





    2. To find out more about the Weatherization Assistance Program, contact your local community action agency, housing authority, or local government for information.






    3. Keep this brochure with your lease or rent contract.



    4. Printed by



    5. State of Washington

    6. Department of Commerce

    7. Housing Improvements and Preservation Unit

    8. PO Box 42525

    9. Olympia Washington 98504-2525



    10. Exhibit 1.3.3C



    11. Owner/Agency

    12. Agreement

    13. &

    14. The Weatherization

    15. Assistance Program










    16. Owner/Agency Agreement &

    17. The Weatherization Assistance Program



    18. Your role as owner in an energy-saving partnership



    19. As the owner of residential rental property, you have an opportunity to weatherize your property by joining a partnership with your local community action agency, housing authority, or local government agency.

    20. By joining a partnership, the cost of completely weatherizing your property will be greatly reduced.

    21. The Weatherization Assistance Program is designed to provide funds for income-eligible tenants. With your assistance, weatherization measures can be installed that will increase the value of your property without raising the property tax.

    22. In addition, your tenants will benefit through greater comfort and reduced utility costs, and your investment will last for years.

    23. About the Weatherization Assistance Program



    24. The Weatherization Assistance Program is a state and federally funded program managed locally by community action agencies, housing authorities, or local government agencies.

    25. The program provides professional energy management through:

    • Building energy analysis

    • Attic insulation

    • Crawl space insulation

    • Sidewall insulation

    • Furnace repair or replacement

    • Heating duct sealing and insulation

    • Water heater and water pipe insulation

    • Weatherstripping and caulking

    • Other draft reduction and energy-saving measures

    1. All rental units are eligible, whether single family homes or apartments, as long as the occupants are income-eligible.

    2. Prior to weatherization, federal law requires that the weatherization agency and the owner of the rental property sign an agreement. The agreement, known as

    3. The Owner/Agency Agreement, has the following provisions:

    1. The rent you charge your tenants cannot be increased for any reason for a period of one year following completion of the weatherization work.

    2. During the second year after the weatherization work is completed, rent can only be increased for the following reasons:

    • To recover costs related to property tax increases

    • To recover the actual cost of improvements to the dwelling, other than weatherization, that are performed after weatherization is completed and which directly benefit the tenants.

    • To recover the cost associated with an increase an in operation and maintenance.

    1. For a period of three years after weatherization is completed, your tenant shall not be evicted, except for good cause, such as

    • Failure to pay rent

    • Damaging property

    • Creating a nuisance or violating any terms of the rent agreement

    1. If the property is sold within three years from the date weatherization is completed, one of the following applies, the seller must:

    • Pay back the cost of weatherization on a pro-rated basis. OR

    • The new owner must accept full responsibility and enter into and sign a new Owner/Agency Agreement.



    1. Living in a weatherized home



    2. Now that your home has been weatherized, don’t waste energy. Space and water heating are the two largest residential energy users.



    3. To save energy:



    4. Setting your thermostat at 68o Fahrenheit will save energy. If you feel cool, wear a sweater or dress in layers



    5. If you are too warm, turn down the heat. Don’t open a door or window to cool down.



    6. At night, cover the windows. This will help keep the heat in.



    7. Furnaces and other heating systems should be checked annually to ensure efficient operation.



    8. Storing boxes and things on top of the insulation will reduce its ability to keep you warm. Make sure the insulation stays the way it was put in.



    9. Water heaters should be set at 120 degrees (120o Fahrenheit).





    10. Saving energy is saving money!



    11. For more information on how to save energy, contact your local community action agency.






    12. Keep this brochure with your lease or rent contract.



    13. Printed by



    14. State of Washington

    15. Department of Commerce

    16. Housing Improvements and Preservation Unit

    17. PO Box 42525

    18. Olympia Washington 98504-2525



    19. Exhibit 1.3.3D



    20. Tenant Rights

    21. &

    22. The Weatherization

    23. Assistance Program






    24. Tenant rights and the Weatherization Assistance Program

    25. Congratulations!

    26. Your home is about to be weatherized. The addition of insulation and other energy-saving measures will make your home more comfortable and save you money!

    27. Know your rights

    28. The Weatherization Assistance Program is designed to benefit you. Most, if not all, of the materials and labor to weatherize your home are being supplied free of charge to the owner. In return for this free service, the owner has agreed to the following items:

    29. No Rent Increase – The owner cannot raise your rent for any reason for a period of one year from the time the weatherization work has been completed.

    30. During the second year after your home has been weatherized, the owner can only raise your rent for the following reasons:

    1. Actual increases in property taxes

    2. Actual cost of improvements (other than weatherization) to the dwelling that directly benefits you, the tenant; and

    3. Actual increases in cost of maintenance and operations of the property.

    1. Evictions – Beginning on the date the owner signs the agreement to weatherize your home, and for three years after, the owner cannot evict you, or attempt to evict you, except for good cause, such as failure to pay rent, violating any provision of the lease or rent agreement, damaging property or creating a nuisance.

    2. Sale of Property - If the owner sells the property within three years after the weatherization work is completed, the owner must either get the new owner to accept the agreement and protect your rights as stated above, or pay back the cost of weatherization.

    3. If you need help

    4. If you feel the owner is not following the agreement as explained, contact your local legal services office, community action agency, or the agency that did the weatherization work. They may be able to help you.

    5. Remember…

    6. The owner has signed an agreement (Property Owner/Agency Agreement) in order to have your home weatherized. The agreement states that:

    • Your rent will not be increased for one year for any reason.

    • For one additional year, your rent can only be increased for specific reasons.

    • For three years, you cannot be evicted except for good cause.

    • If the property is sold, your rights will be protected as explained, or you will be notified that the new owner is buying back the weatherization.


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