For 1 to 4 Family House? Yes No  
For a Multifamily Building? Yes No
Number of Units in building _______ Complete "Energy Information - B" for each occupied unit
Heating Fuel:
Natural Gas Electric Propane Oil Wood Other _____________________
Secondary Heating fuel (if any) that you sometimes use:_____________________________________________________
Name and address of Heasting fuel supplier:
Account number (if gas):
Electric Utility: (check the one that provides your electric service)
Niagara Mohawk (NMPC)
Long Island Power Auth. (LIPA)
Consolidated Edison (Con Ed)
Central Hudson Gas & Electric (CH)
Orange & Rockland (O&R)
Rochester Gas & Electric (RGE)
NYS Electric & Gas (NYSEG)
Electric Account number:
Customer Authorization for Release of Fuel/Energy Bills (past 2 yrs. and next 2 yrs.)
To: Fuel and Electric Suppliers listed above:
I hereby authorize you to release information on my fuel bills, both past and future, to the following subgrantee or its designee.
Name of Weatherization Subgrantee:
Number and Street: City: Zip Code:
I understand that this information is being made available to help to evaluate my energy use patterns in order to identify potential and actual energy savings resulting from work performed or services offered through the weatherization assistance program.
Customer Name: Customer Signature:___________________________ Date:
Number and Street: City: Zip Code:

Service Agreement for Heating System:
Do you currently have a service maintenance agreement for your heating system? Yes No
If yes, please supply name, address and phone number of the service maintenance provider.
Name of Service Provider:
Number and Street: City: Zip Code:
Note: If there are account numbers in addition to those identified above, please attach a list of the numbers.
Please fill the form and send it via regular mail to us, please print it before leaving this page, any filled area will get deleted or clear if you navigate out of this form.

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