Have you had a Home Performance with ENERGY STAR® Assessment completed at your home within the past five years?

Yes

No

Refer to the table below; based on the number of occupants in your home, is your annual gross household income at or below the second row limit?

Total Number of Occupants Living in the Home	1	2	3	4	5	6	7	8	For Each Additional Family Member
200% of 2021 Federal Poverty Level Income	$25,760	$34,840	$43,920	$53,000	$62,080	$71,160	$80,240	$89,320	Add $9,080

Yes

No

Do you live in a single-family home (between one and four units under one roof) or a building with five or more units under one roof?

Single-family home

Five or more units under one roof

Do you own the home, or do you rent?

Own

Rent