ENERGY EVALUATION FORM

Name:
Street:
City:
State:
Zip:
Daytime
Phone:
Evening
Phone:
E-mail:

1. Your Home was built in what year?
2. Moved into home?
3. Number of people living at home?
4. Own or rent:
Own Rent
5. Thermostat is set at:
Summer Winter
6. Thermostat is:
Manual Programmable
7. Condition of your ducts are:
Poor
Average
Good
Unknown
8. Wall Insulated:
Yes No
9. Floors Insulated:
Yes No
10. Attic Insulated:
Yes No
11. Home fuel type:
Wood
Electric
Natural Gas
Fuel Oil
Propane
12. Type of home?
Detached single-family
Townhouse/Condominium
Apartment
Duplex
Manufactured Home/Mobile
Other
13. Construction type?
Wood Frame
Block
Other
14. Foundation:
Slab
Enclosed crawl space
Open crawl space
Basement
15. Type of windows:
Single pane
Double pane
Triple pane
16. Do you have storm windows?
Yes No
17. Type of exterior doors in your home:
Hollow wood
Solid wood
Insulated metal
Fiberglass
18. Do you have a storm door?
Yes No


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Heinmiller Heating & Cooling
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