Step 2 Test — Advanced Home Energy Solutions

First and Last Name

Email address

What is the age of the individual that requires assistance?

In what City and State does the individual currently reside?

Does the individual currently have children of any age?

Yes No

Is the individual a veteran, a wartime veteran or the widow / widower of one?

Yes No

Is the home built before 1978?

Yes

If yes, has the home been checked for Asbestos insulation?

Yes

Has the paint been tested for lead?

Yes

Do you work with any city, county or non-profit organization?

Yes

What is the total combined amount of all utility bills at the residence?

What is your relationship to the person who requires assistance?

What is the marital status of the person that requires assistance?

1 out of 3

Which of the following statements is true or best relates to your current situation?

We are looking for the lowest payment possible We are looking for a higher payment with a shorter term We are looking for no payment for the first year We are looking to offset payment with Energy savings and tax benefits

Within what range would you say your credit score is?

-500 501-599 600-650 651-700 701-750 751-850

Do you work in the field of law enforcement, first responder or the medical field?

Yes

Are you a teacher or do you work in the field of education?

Yes

Are you over the age of 65 or currently retired?

Yes

Have you served within any branch of the military?

Yes

Estimated value of the home?

Current mortgage payment?

Has anyone in the home been affected by COVID-19

Yes

How soon are the financial resources or assistance required?

Does the person in need of assistance own and live in their home?

Yes

2 out of 3

What is the annual income of the individual in need of assistance?

What are the total assets of the individual in need of care not including their home? If married, divide by two.

Can the individual file taxes in either of the following ways?

Married/RDP filing jointly Registered domestic partners (RDP) Qualifying widow(er) Head of household

What is the health of the person that needs care?

Does the individual in need of care have a life insurance policy valued at over 50,000 dollars?

Yes No

What types of insurance and / or public benefits the individual in need of assistance currently has or receives.

Medicaid Medicare Medicare Supplemental Insurance Medicare Advantage Plan TRICARE / TFL or CHAMPVA /CFL Social Security SSI Social Security Disability Long Term Care Insurance Other Private Health Insurance Has No Insurance

Please provide your email address

3 out of 3

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