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Refrigerator Replacement Program Application 
**MAKE AND MODEL ARE REQUIRED

General Information

Date:
 Electric Utility Company:
 Electric Utility Account #:
Client Name:
 Landlord Info (if applicable):
Client Address:
 Landlord Address:
City, State, Zip:
 Landlord City, State, Zip:
Client Phone:
 Landlord Phone:

Refrigerator Information:

Make:
 Model:
 Year:
 Color:
 Size:
Freezer Location:
 Current Temperature Setting (Examples, 1, 2, 3 etc.):
Does it keep your food cold?
Yes No 		Does it over-freeze?
Yes No
How often do you hear it running?
Comments:

Personal Information:

# of people in Household:
 Average Monthly GROSS* Income:
Type(s) of Income:
Earned Child Support TANF Social Security Pension None Other
*Gross Income is all income before taxes.

Renter Information (if applicable):

Who is responsible for the electric bill?
 Who owns the refrigerator?

Miscellaneous Information:

Has your home ever been weatherized? Yes No
Have you ever attended a Project Share Workshop? Yes No
If you have, did your receive a cloth bag of energy saving materials? (ie: window plastic, caulk ,etc) Yes No
Can you or someone you know, move the refrigerator away from the wall if necessary? Yes No
How did you hear about the program?

Copyright © 2004, Spokane Neighborhood Action Programs