Form

Energy Smart Eastside is offering free heat pumps to qualified adult family homes within the city limits of Bellevue, Issaquah, Kirkland, Mercer Island, Redmond and Sammamish. Funding is limited. Please submit one application per adult family home. Applications close at 5:00pm on April 4.

For alternate formats, interpreters, or reasonable accommodation requests, please phone 425-452-5362 (voice) or email energysmarteastside@bellevuewa.gov.

First Name*

Last Name*

Email*

Phone Number*

🇺🇸

Street Address*

Eastside City*

State of Residence*

Adult Family Home Name*

Washington State Adult Family Home License Number*

What type of Adult Family Home do you operate?*

Select all that apply.

Elderly Care

Memory Care

Disability Services

Do you own or rent the property?*

Own

Rent

Landlord First Name

Landlord Last Name

Landlord Phone Number

Current Primary Home Heating:*

Approximate age of your primary heating source

What best describes the available air conditioning in the home?*

How many residents does this adult family home serve?*

How many residents in this adult family home are funded by Medicaid?*

How many staff work in this adult family home?

Do you co-own the AFH with another person?

Yes

Is this adult family home a woman and/or minority owned business?

Yes

By submitting this form I attest that I am the operator or authorized representative of the operator of this adult family home and that the above answers are true and accurate.