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What is your preferred language?*

English

Spanish

Portuguese

Haitian Creole

Cape Verdean Creole

Vietnamese

Mandarin

Cantonese

Khmer

Arabic

Another language

Is the building you are inquiring about a home or a business?*

Home

Business

Select the benefits you are interested in by checking the boxes below. Check all that apply.

No-cost Home Energy Assessment

Heating, ventilation, and air conditioning (HVAC)

Heat pumps

Solar energy

No-cost Energy Assessment for Businesses

What is your first name?*

What is your last name?*

Primary Phone Number

Secondary Phone Number

Primary Email Address

How did you hear about the program?*

Social media

From a friend

Letter/flyer

At an event

Another organization

Someone came to my door

Other

What is the address of the building you are inquiring about?*

Address

Address Line 1

Address Line 2

City

Postal Code

Do you own or rent your unit/home?*

I own

I rent

Please select which applies best to you.*

Only I occupy the building.

Only tenants occupy the building.

Both tenants and I occupy the building.

What is your home heating fuel?*

Gas

Oil

Electricity

Propane

Other

Who is the electric utility?*

Eversource

National Grid

Municipal

Unitil

Liberty

Who is the gas utility?*

Eversource

National Grid

Unitil

Liberty

Berkshire Gas

Whose name is on the electric and/or gas bills?

My landlord

My tenant

Do you receive any discounted rates on your electric and/or gas bills?*

Yes

Not Sure

Do you receive fuel assistance to help pay for your winter monthly heating costs?*

Yes

Not Sure

Do you receive any of the following benefits? (Please click “list of benefits” to see the list of benefits)*

Yes

Not Sure

List of Benefits

Do you live in a condo or housing association?*

Yes

How many units in total are there in the condo or housing association?*

5/5+

How many units in total are there in your building?*

5/5+

Have you received a no-cost Mass Save Home Energy Assessment at the same address within the past 2 years? Has anyone come to your home to assess your energy use and provide you with energy-saving items like light bulbs, faucet aerators, showerheads, etc.?*

Yes

Not Sure

Were any weatherization (insulation and/or air sealing) upgrades recommended as a result of your energy assessment?*

Yes

Not Sure

Did you complete all recommendations?*

Yes

Not Sure

What is your first name?*

What is your last name?*

What is the name of the business you are inquiring about?

What is your role in the business?*

Primary Phone Number

Secondary Phone Number

Primary Email Address

How did you hear about the program?*

Social media

From a friend

Letter/flyer

At an event

Another organization

Someone came to my door

Other

What is the address of the building you are inquiring about?*

Address

Address Line 1

Address Line 2

City

Postal Code

Do you own or rent the space where the business is located?

I Own

I Rent

What is your heating fuel?

Gas

Oil

Electricity

Propane

Other

Who is the electric utility?*

Eversource

National Grid

Municipal

Unitil

Liberty

Who is the gas utility?*

Eversource

National Grid

Unitil

Liberty

Berkshire Gas

What is the approximate square footage of the space?

What kind of business is it?*

House of worship

Restaurant

All Other (retail, small office, manufacturing)

Please pick which type best describes your business below.*

Retail

Small Office

Manufacturing

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Summarizing Answers

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List of Benefits

Low Income Home Energy Assistance Program (LIHEAP/Fuel Assistance)	Supplemental Nutrition Assistance Program (SNAP/Food Stamps)
Supplemental Security Income (SSI)	Veterans Dependency & Indemnity Compensation (DIC) Surviving Parent or Spouse
MassHealth – Basic or Standard	School Breakfast/Lunch Program
Emergency Assistance for the Elderly, Disabled & Children (EAEDC)	Veterans Non-Service Disability Pension
Public or Subsidized Housing	Commonwealth Care Plan Types 1, 2 or 3A
Transitional Aid to Families with Dependent Children (TAFDC)	Health Safety Net Plan – Primary or Secondary (Not Partial)
Head Start	Women, Infants & Children (WIC) Nutritional Program
Veterans’ Service Benefits (Chapter 115)

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