Evanston Green Homes Participant Application and Agreement

Participant Information

First Name:

Last Name:

Mailing Street:

Mailing City:

Mailing State:

Mailing Zip:

Is the building address the same as your mailing address?

Census Tract:

Building Street:

Building City

Building State:

Building Zip:

Census Tract:

Phone Number:

Email:

Which of these best describes you?

How many units are in the building?

Do you understand and acknowledge that this program has a 5-year affordability preservation requirement that obligates you to keep the same number of currently affordable units affordable for the next 5 years based on IHDA’s rent limits?

Have you made any upgrades to your property to be compliant with ADA (American with Disabilities Act) standards?

Do you occupy this property?

Property Manager or Authorized Party Contact

Company Name:

First Name:

Last Name:

Email:

Phone:

Questions for Occupied Properties

Goals & Outcomes

Which of the following outcomes are you hoping to get out of participation in this program? (Ctrl+ click to select all that apply)

Other (please specify):

How long have you lived in your home?

Which of the following, if anything, are you currently unsatisfied with in your home? (Ctrl+ click to select all that apply)

Other (please specify):

Energy Efficiency

How would you describe the air quality inside your home?

How well does your home keep cool on warmer days?

How well does your home keep warm on colder days?

How often do you need additional appliances (outside of your home’s regular heating, ventilation, and air conditioning system), such as space heaters, box fans, and window air conditioners, to keep your home at a comfortable temperature?

Energy Security

In the past year, how often did your household cut back on or skip expenses for basic needs, such as food or medicine, in order to afford utilities?

In the past year, how often did you reduced your energy consumption to uncomfortable or inconvenient levels to save on utilities?

In the past year, how often was your household disconnected from electricity, gas, or water service because you were unable to pay?

Which (if any) of the following utility assistance programs have you participated in?

Other (please specify):

Household Health

In general, how well would you rate the health of members in your household?

Have you or anyone in your household been told by a doctor, nurse, or other health care professional ever told you that you had any of the following? (Ctrl+ click to select all that apply)

In the last 4 weeks, how often did your household’s respiratory conditions interfere with normal work/school activities (including both inside and outside the home)?

In the last 4 weeks, has anyone in your household had to visit an urgent care or emergency room related to these respiratory conditions?

Authorization

By checking this box, I certify I have read and agreed to the Terms and Conditions Below. Your responses to the following are not legally binding. The option of a formal program agreement will be presented to you following an assessment and a summary of health, safety, and energy recommendations for your property

I certify

Elevate’s obligations are to:

Conduct healthy homes assessments at no cost to the participant

Review utility usage bills from the previous 12 months as provided by the participant

Provide a written report of the results of the assessments and recommendations for retrofits or upgrades

Identify work to be undertaken at the property, which the participant will have the right to approve or disapprove

Upon participant approval, engage one or more contractor(s) to perform the work at no cost to the participant

The Participant’s obligations are to:

Cooperate with Elevate to schedule energy assessments and with contractors engaged in construction work

Provide accurate income and geographic location documentation

Prepare the work site for contractor access, including moving furniture and appliances

Give permission for Elevate and for contractors engaged in this program to use information gathered about the Property for their own purposes, such as communications with other contractors working on the project, program improvement, or case studies

Share utility billing data or agree to authorize Elevate’s access to utility data from the provider

Maintain the property in habitable condition

Not interfere with or attempt to modify the scope of work, if any, approved by Elevate together with the participant

Comply with all applicable laws including, but not limited to, the Lead Poisoning Prevention Act (41 ILCS 45/) and the Illinois Radon Awareness Act (420 ILCS 46/), which may require notification of current and/or future property occupants about lead and/or radon testing and/or remediation. In no event will Elevate be responsible for ensuring Participant’s compliance with any applicable laws.

Liability

Elevate shall not be liable for injury to or death of any person or damage to any property (including the Building) in connection with the Program or otherwise, except to the extent caused by the sole gross negligence or willful misconduct of Elevate. You agree to indemnify Elevate and hold it forever harmless from and against any loss, cost, damage or expense, including reasonable attorneys’ fees and costs, arising out of or relating to your participation in the Program and/or Participant’s acts or omissions. IN NO EVENT WILL ELEVATE BE LIABLE FOR ANY INDIRECT, CONSEQUENTIAL, SPECIAL OR INCIDENTAL DAMAGES OF ANY KIND.

Signed By (your name):

Contact Information