HEARTHome Electrification Affordability Rebates and Technical Assistance ProgramHEARTHome Electrification Affordability Rebates and Technical Assistance ProgramHomeHow It WorksEnergy Billing OverviewFAQ/SupportContractorsApply Now Site Menu HomeHow It WorksEnergy Billing OverviewFAQ/SupportContractorsApply Now Pre-Screening Application You must have JavaScript enabled to use this form. Primary Applicant Full Name First Name Last Name Address Street Address Street Address 2 City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Phone Number Email Address Preferred Language Household Information How many people are currently living in the household? What is the total household income? How many members of the household currently earn income? Are you the homeowner or tenant of the household? Yes No If you are a tenant, what is the term of your lease? If you are the tenant, is the homeowner aware that you are applying for this program? Yes No Homeowner Information Homeowner Full Name First Name Last Name Homeowner Phone Homeowner Email Additional Questions Was your household affected by the floods that occurred in January 2024? Yes No What were the property damages? Have you or anyone in your household received rebates, incentives or relief aid for appliances through any local, state or federal programs? Examples: TECH Clean California, VOAD, California Energy Smart Homes, SDCP Equitable Building Decarbonization program, Environmental Health Coalition or Casa Familiar programs Yes No Please list the program(s). Does this property currently use or plan to install any solar power, home battery storage, or similar systems? Yes No Please specify which system and when this technology was or will be installed. Depending on the cost of the retrofit it might not be fully covered by the rebate. If that’s the case, what would be the maximum amount you would be willing to spend out-of-pocket? Electrical Paneling Do you know what the electrical panel capacity is for the household? Yes No Please enter the panel capacity. What type of electrical paneling does the household have? Examples: Main Breaker Panels, Main Lug Panels, Fuse Box, and Knob and Tube wiring systems What appliances are currently installed in your household, and are they powered by natural gas, electricity, or a combination of both? Examples: dryer, water heater, cooktop, HVAC system, electrical panel/wiring Have you done any appliance retrofits in the household in the past two years? Yes No Please list any rebate or incentive programs used. Which household appliances need to be retrofitted, and what energy-efficient replacements are you interested in receiving? Please list each appliance in order of priority and include any preferred Energy Star Certified brands or specific models, if known. Are there any known health or safety concerns in the household, such as mold, asbestos, lead paint, or similar hazardous materials? Yes No Please describe any conditions that may affect the safety of occupants or contractors. Are there any known issues with your plumbing or electrical systems? Yes No Please describe these issues in a few sentences. Leave this field blank
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