Room Heat Pump Application

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Thank you for participating in Rising Sun's No-Cost Appliance Upgrade Program. The following application will help determine if you are eligible to receive a full no-cost replacement of a Room Heat Pump.

This application may require you to move around your house to collect information about your appliances. If you would rather take this application via phone with a Rising Sun staff member, please call (209) 890-4341 ext. 369 to set up an appointment. You may also email us at applianceupgrade@risingsunopp.org with any questions that you have.

Contact Information

Name

Email Address

If you do not have an email, please type: noemail@noemail.com

Phone Number

Preferred Language for Contact

EnglishSpanish

Complete Street Address

E.g. 123 Main St

Zip Code

E.g. 92321

Household Information

What type of house do you have?

How many bedrooms are in your home?

How many people currently live in the home?

What is your annual gross household income?

If you don't know the exact amount, an approximate amount is sufficient

Homeowner Status

Do you own the property that you are applying for?

YesNo

Renter/Tenant Section

You have indicated that you are a renter. As a renter, do you own your cooling system?

YesNo

If not, does the landlord own the cooling system?

YesNo

If deemed eligible for items that are owned by property owner or landlord, would you be comfortable with Rising Sun reaching out to them for their approval?

YesNoIf you select no, you will not be eligible for these items

Landlord Name

Landlord Phone Number

Landlord Email Address

End of Survey

Are there any additional notes or comments you would like to make?

Please check the box below to confirm that all of the answers on the form are correct to the best of your knowledge