Weatherization Application

I hereby apply for weatherization assistance through the Low-Income Weatherization Assistance Program, or LIWAP, administered by Missouri Department of Natural Resources’ Division of Energy and implemented by the weatherization agency with whom I am filing this application. I authorize and direct any federal, state or local agency, organization, business or individual to release to the weatherization agency any information needed to verify my application for weatherization assistance. I further authorize and direct the weatherization agency to release information to other entities for the purpose of determining my household’s eligibility for the LIWAP.

I authorize the release of my billing and utility consumption history from my utility vendors providing service to the residence for which I request weatherization assistance, and those vendors are hereby released from any liability for providing information to the weatherization agency.

I understand information relating to my eligibility application or participation in the program, such as name, address, or income information, are generally exempt from disclosure and requests for such information will be treated by the Department of Natural Resources’ Division of Energy consistent with the federal government's treatment of information requested under the Freedom of Information Act (FOIA), 5 U.S.C. 552, including the privacy protections contained in Exemption (b)(6) of the FOIA. A request for release of my personal information including but not limited to my name, address, or income information requires the Department of Natural Resources’ Division of Energy to balance a clearly defined public interest in obtaining this information against my legitimate expectation of privacy. If a legitimate, articulated public interest is found, the Department of Natural Resources’ Division of Energy may release my information in the aggregate with other recipients’ information.

I understand that funds for weatherization assistance for my residence may be provided by federal and state agencies, utility vendors, and other sources, and I hereby agree that my information, to the extent not specifically required to be kept confidential pursuant to the federal Privacy Act and Freedom of Information Act, and Missouri laws including the Sunshine Law, may be released by the Department of Natural Resources’ Division of Energy to qualified personnel for research, audits, program evaluation or reports, with appropriate restrictions on the use of that information (i.e., not to be released to the public). If I receive LIWAP services, I specifically authorize the Department of Natural Resources’ Division of Energy to release information regarding my identity, address, weatherization services performed on my residence and other pertinent information, to my utility vendors or other appropriate entities for use in analyzing the effects of weatherization on utility usage, for other research, or for required reporting purposes. This authorization does not constitute public release of my identity, and I understand the Department of Natural Resources’ Division of Energy will not publicly release or permit public release of my personnel information, and will place appropriate restrictions on use of my personal information. Highly sensitive information such as Social Security numbers, income or medical information will be protected from disclosure under the Privacy Act and Freedom of Information Act, as well as the Missouri Sunshine Law.

Civil Rights Statement
No person will be denied or discriminated against in connection with any program or activity receiving federal financial assistance from the U.S. Department of Energy because of race, color, national origin, age, sex or disability.

Access to Residence/Conditions
I agree and understand the Department of Natural Resources’ Division of Energy staff, weatherization technicians and contractors must be given access to all areas of my home during business hours and on a reasonable schedule.

My signature below authorizes the Department of Natural Resources’ Division of Energy employees, the weatherization agency employees, contractors and subcontractors to enter my home as needed to perform energy audits, weatherization work and inspections of weatherization work and such persons will not be held liable for any injury or expense incurred by me while participating in this program.

I agree and understand that if my home is deemed unsafe or unacceptable for weatherization technicians, contractors or inspectors to perform their duties due to unsafe or dangerous conditions, presence of debris, clutter, mold, insect/rodent infestation, pets, threat of violence, etc., the project will be postponed until these conditions are corrected.

I agree to allow my home to be photographed for pre-and post-work documentation.

I understand that in order to weatherize my home, holes may be drilled in walls (particularly outside walls) to install insulation. I understand holes will be plugged as part of the weatherization service, but that it is my responsibility to paint the plugs used to fill these holes. I also understand that older vinyl or other siding may be damaged during this process.

Closing Certification
My signature verifies this residence is not currently for sale, nor is it designated for acquisition, clearance or foreclosure by federal state or local programs, and has not been weatherized previously (unless work was performed prior to Sept. 30, 1994). Upon completion of work, I give permission for the contractor, subcontractor, the weatherization agency employees, the Department of Natural Resources’ Division of Energy employees and federal officials to inspect that work.

I certify the information provided in this application is true, correct and complete to the best of my knowledge. I understand that I may be fined, imprisoned or both under state or federal law if I make false statements on this application in order to get benefits I am not eligible to receive. LIWAP service is free of charge, but I understand that if my home is served due to incomplete or incorrect information that would otherwise make my household ineligible, I accept responsibility for paying for services received.

My signature below indicates that I have read, understood and agree to the conditions of this application.

I certify that the information on this application is true and accurate to the best of my knowledge and belief. I understand that such information is subject to verification and I further realize that falsified or fraudulent information may result in the rejection of this application.

Under the terms of this Agreement, CLIENT agrees to release to CMCA information that is confidential and proprietary to be used solely for the Agency's related statistics, services and programs. Confidential Information refers to any and all information of a confidential, proprietary, or secret nature which is or may be related in any way to the family, medical records, job history, present or future, of CLIENT or any related data. Confidential Information includes, for example, but not limited to: spouses or other family members, ages, salaries, financial standings, criminal records, medical records and all other pertaining to the family information. CMCA will consider all information received from CLIENT to be strictly confidential, as required by the Privacy Act, and subject to the restrictions of this Agreement; except for information that is: (i) generally known to the public, (ii) in the possession of CMCA before receipt from CLIENT, (iii) obtained later by the Agency from a third party without restriction or violation of Agreements.

CMCA will not disclose CLIENT's Confidential Information to any other party without the prior written consent of CLIENT. CMCA may, however, disclose Confidential Information to its employees and/or programs but only if the employee has a legitimate need to know and has agreed to terms similar to those in this Agreement. Community Action Agency may also disclose this Confidential Information (i) to medical personnel in an emergency; (ii) to qualified personnel for research, audits, or program evaluation, as long as CLIENT identities are not identified; (iii) to a third party based on court orders; and (iv) to appropriate authorities in cases of suspected child abuse or neglect. CMCA will be responsible for any use or disclosure of Confidential Information by any of its employees or agents to third parties who should not share this information.

This Agreement may be amended only in writing and shall be governed by the laws of the State of Missouri.

Please sign below to indicate that you have read this consent and agree with its terms.