I,   Name of appliacant  , have applied for weatherization assistance with CSRA Economic Opportunity Authority, Inc. on   Date    . I fully understand that this authorization form is a part of the intake process and shall be completed before any weatherization work can be performed.

I,   Owner/Authorized agent   , certify that I am the owner of the dwelling unit located at    Address  . I do hereby authorize CSRA Economic Economic Authority to make energy related repairs* and release CSRA Economic Opportunity Authority from all liability whatsoever in the performance of this Authorization as as the work has been completed in a workmanlike manner.

I,   Owner/ authorized agent   , certify that I am the owner of hte dwelling unit located at   address   . I do hereby authorize CSRA Economic Opportunity Authority to make energy related repairs* and release CSRA Economic Opportunity Authority from all liability whatsoever in the performance of this authorization as long as the work has been completed in a workmanlike manner. I fully agree that following the completion of repairs the rent shall not be raised for a period of two years because of increased value of the dwelling unit due solely to weatherization assistance and understand that no undue or excessive enhancement shall occur to the value of the dwelling unit.

I   address   , hereby authorize   Fuel supplier   to release Information on my fuel records and data both past and future to CSRA Economic Opportunity Authority if requested. I understand that this information will be used only to provide data for the above named agency, and no information obtained through this release shall be made public in such a manner that the dwelling or occupants can be identified,

The secure and verifiable document provided with this affidavit can best be classified as:   Form of documentation    

Executed in   City   ,   State