NPTHA Climate Pollution Reduction Grant (CPRG) Residential Energy Program Application

Tribal code

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PO Box 188 Lapwai, ID 83540 P: (208)843-2229 F: (208)843-2973

Email: chloet@nezperce.org

Application cover page

The program will provide Wood Stove Change Outs (WSCO) (WOOD STOVES HAVE TO BE 20 +

YEARS OLD) and weatherization services (including, but not limited to, home energy audits,

sealing air leaks, exterior wall installation, window and door stripping, limited window

replacement, minor roof repair, air source heat pump installs, etc.) for qualifying homes to

improve indoor air quality, reduce safety hazards, and increase energy efficiency for

participating households. Our goal is to reduce greenhouse gas emissions in residential homes.

Who qualifies:

• Tribal homeowners/renters who live within the Treaty of 1863 Nez Perce reservation

boundary

PRIORITY:

• Nez Perce Tribal elders 62+

• Nez Perce Tribal homeowners

• If you have a safety concern regarding your heating and/or cooling

Please turn in the following:

Copy of Tribal documentation

Copy of homeownership documentation

If renting, provide copies of proof of residence and landlord ownership documentation

HOMEOWNER

A homeowner may complete this application on their own behalf. The homeowner’s signature

is required for program eligibility, approval, and authorization of services.

RENTER

If the applicant is a renter, both the renter and the homeowner/landlord must complete all

applicable sections of this application. The homeowner/landlord must complete and sign the

required certification section of this application as a condition of eligibility and program

approval.

We will contact you regarding the status of your application within two weeks of receiving

your completed application. Contact us if you need assistance completing this application.

Approved on: 3/10/26

General information

DOB

Homeowner

Enrollment number

Facebook Messenger name

First & Last Name

Tribe

Phone/Cell

Mailing Address

Physical Address

Directions to your home

Renter

Landlord information (if renting)

Landlord name

Landlord email

Landlord phone/cell

Year of home

Type of home Stick built

Do you have electricity?

Do you have a heat pump?

Type of cooling:

Do you have homeowners’

insurance?

General home information

Square footage of home

Manufactured

Single wide

Other:

Yes

Electricity Provider (Include

account number)

Yes

Do you have baseboard heating?

Yes

General concerns:

Do you have a Smoke + Carbon

Monoxide (CO) alarm or smoke

alarms? If yes, what year?

Weatherization information

Have you had a home energy audit? Yes

If yes, what year?

Have you had any weatherization upgrades?

If yes, what kind? (some examples: insulation or weather stripping)

Yes

What type of weatherization is needed in your home?

Do you own an

air cleaner?

Yes

If yes, how often M

do you use it?

Hours a day: 1 2 3 4 5

Wood stove information

Yes

If yes, year of wood stove

No If yes, why?

Do you have a wood stove?

Do you believe your

Yes

wood stove is a fire

hazard?

Rank your wood stove (highest number being most hazardous): 1 2

How long do you dry your Weeks

1-3 months

3-6 months

firewood before burning?

How/Where do you get

NPT Wood

Cut your

Purchase

wood?

program

own wood

6 7

4 5

6-12 months

Other:

Never

More than

12 months

Where do you store

your firewood?

Stacked in

Pile on the

Stack off the

Other:

the shed w/

ground w/ tarp

ground and

roof

covered

List ALL household members here, enter the head of household on the first line.

First & Last Name

Date of birth

Tribal Affiliation

Source of income

Are there any household members who are disabled in your home?

Yes

If yes, please list

Wood stove question: Does the person building the fire/operating the wood

Yes

stove have any ADA accessibility needs? (location of air control/damper handles)

Do any of your household members have a lung, heart or blood condition?

Yes

Additional information:

HOMEOWNER CERTIFICATION

Signature clause

Homeowner Certification (regarding consent)

Please initial each item below to indicate your consent regarding access, education, photo/video and

weatherization (note: additional contracts may require further authorization):

Access

_____I agree to allow the NPTHA CPRG Residential Energy Program employees access to my home for necessary

initial assessments and post assessments, including the duration deemed necessary during contractual work.

_____ I agree to provide reasonable access to my home for the NPTHA CPRG Residential Energy Program’s

approved contractors to complete all approved weatherization work deemed necessary.

_____Furthermore, if I’m unable to be present, I will inform the NPTHA CPRG Residential Energy Program of

further access to my home for both the NPTHA CPRG Residential Energy Program employees and approved

contractors. Consenting to this may be verbally and/or written. This portion is to avoid any delay in providing

work completion.

Education

_____I acknowledge and agree to receive education and informational materials provided through the NPTHA

CPRG Residential Energy Program, including but not limited to topics related to weatherization, wood stove

change outs, energy efficiency measures, and the reduction or elimination of greenhouse gas emissions.

Photo/Video

_____I acknowledge that the NPTHA CPRG Residential Energy Program will take photographs and/or video of

my home and surrounding areas on my property for program documentation purposes.

Weatherization

_____I agree to allow the NPTHA CPRG Residential Energy Program’s approved contractors to install an air

intake, which may require cutting a hole in a wall and/or floor as necessary for proper airflow for safe and

effective wood stove operation. (The hole will be sealed according to code)

_____ I agree to allow the NPTHA CPRG Residential Energy Program’s approved contractors to install an air

source heat pump if needed, to allow heating/cooling for my household, which will require cutting a hole in a

wall for proper installation.

_____ I agree to allow the NPTHA CPRG Residential Energy Program staff to install a Smoke + Carbon Monoxide

Alarm and Smoke Alarms as needed.

_____Additionally, I authorize the NPTHA CPRG Residential Energy Program to access my utilities to gain

information pertaining to monthly usage throughout the term of this grant.

I certify that I am the legal owner of the property listed above or have the legal authority to approve the work

described. I understand the scope of work may involve structural modifications necessary to complete

weatherization improvements safely and effectively.

I understand that the NPTHA CPRG Residential Energy Program is relying on this information to verify my

household’s eligibility for program assistance. I certify that all information and answers to the questions

contained in this application are true and complete to the best of my knowledge. I consent to release the

necessary information to determine my eligibility including minors who reside in the home. I understand that

providing false information or making false statements is considered grounds for denial of my application. I also

understand that such action may result in criminal penalties. I authorize my consent to have the program verify

information contained in this application for purposes of providing my eligibility for assistance provided by the

program. I will provide all necessary information including source(s) of income, names, addresses, phone

numbers, where applicable and any other information required for expediting the application process. I

understand that the processing of this application will require providing personal information to the program.

I understand that acceptance is agreeing and abiding by applicable program requirements and policies as they

now exist or as they may hereafter by be revised OR ADDED by the program.

Printed homeowner name:

Homeowner’s signature:

Date:

(ONLY COMPLETE THIS PORTION IF YOU OWN A WOOD STOVE)

I certify the following under the penalty of perjury by signing below:

I understand that providing false information on this application constitutes fraud and will include, but is not

limited to, disqualification from participating in this project and from future wood stove change outs. My

existing wood stove is currently located at the physical address provided above. It is operable and regularly

used as our main source of heat. I understand that the new device must be installed by a NPTHA CPRG

Residential Energy Program participating vendor and installer. I understand that I may not keep or sell

the old wood stove, and the installer will take the old wood stove to an approved recycling facility. I agree not

to replace this new heating device with a non-certified wood stove or other solid fuel device during the

expected lifetime of this new device. I will operate this new heating device in accordance with the

manufacturer's instructions and will follow proper burning practices received from the Participating Vendor

and EPA Burn Wise educational materials. I understand that proper stove installation, operation, burning

practices, and yearly maintenance are critical to the effectiveness of this new device. I will not burn pressuretreated wood, garbage/trash, plastic, or any other prohibited materials. For wood stove/inserts, I will only burn

clean, dry natural firewood (seasoned for at least 6 months) or commercially designed fire logs approved for

wood stoves in this new device. I understand that the NPTHA CPRG Residential Energy program does not

warrant any devices purchased under this program, including, but not limited to the quality, functionality, or

satisfaction of the device. All warranties are through the stove manufacturer and installer. I agree to hold

harmless the NPTHA CPRG Residential Energy Program, employees, and agents from all loss, damage, or

liability that arises out of or is in any way connected with installation or use of the device installed under this

program. I agree to allow access to my home to the NPTHA CPRG Residential Energy employees and

contractors performing the woodstove changeout. I certify the statements and information in this homeowner

application are true, accurate, and complete.

Printed Homeowner name:

Homeowner’s signature:

Date:

RENTERS ONLY

Signature clause

Please initial each item below to indicate your consent regarding access, education, and photo/video

(note: additional contracts may require further authorization):

Access

_____I agree to allow the NPTHA CPRG Residential Energy Program employees access to my home for necessary

pre and post assessments and contractual work.

_____ I agree to provide reasonable access to my home for the NPTHA CPRG Residential Energy Program’s

approved contractors to complete all approved weatherization work deemed necessary.

_____Furthermore, if I’m unable to be present, I will inform the NPTHA CPRG Residential Energy Program of

further access to my home for both the NPTHA CPRG Residential Energy Program employees and approved

contractors. Consenting to this may be verbally and/or written. This portion is to avoid any delay in work

completion.

Education

_____I acknowledge and agree to receive education and informational materials provided through the NPTHA

CPRG Residential Energy Program, including but not limited to topics related to weatherization, woodstove

changeouts, energy efficiency measures, and the reduction or elimination of greenhouse gas emissions.