Project Stove Swap application

Background information

1. Name*

First Last

2. County*

3. Physical address (where appliance is located)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

4. Mailing address (if different)*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

5. Phone*

6. Email (if available)

Current wood burning appliance information

1. Make/model/type of appliance*

2. Year manufactured/installed*

3. Is this a primary, or major, heat source?*

Yes
No

4. Is this a primary, year-round residence?*

Yes
No

5. In a typical heating season, how many cords of wood do you burn?*

Vendor/New appliance information

1. Vendor name*

2. Vendor county*

3. New appliance make/model*

4. New appliance being installed*

Approved EPA-certified wood heating device that has a catalyst or uses hybrid catalyst technology
Energy efficient natural gas or propane furnace
Air-source heat pump (ASHP)

5. Does the Applicant qualify for any of the below listed programs?*

Yes
No

Supplemental Nutrition Assistance Program (SNAP) - Medical Assistance/MinnesotaCare - Women, Infants, and Children’s Program (WIC) - Income-qualified Home Energy/Weatherization Assistance Program - Head Start - Social Security Disability Insurance

Project information

1. How did you hear about this project?*

2. Are you willing to be featured in a success story about the project?*

Yes
No

3. Why are you replacing your old heating appliance? (Please check all that apply)*

Current appliance doesn’t provide adequate heat
Want to reduce indoor air pollution
Health issues from indoor smoke
Convenience
Current appliance provides too much/inconsistent heat
Want to reduce outdoor air pollution
Want to reduce wood consumption and reduce costs
Other (please describe below):

Other

Supporting Materials

1. Itemized estimate from vendor*

Drop files here or

Max. file size: 128 MB.

2. Digital color photograph of existing, installed non EPA-certified or qualified appliance*

Drop files here or

Max. file size: 128 MB.

3. Any other information or documentation relevant to the program

Drop files here or

Max. file size: 128 MB.

Applicant certification

This form is available for download at the top of the page.

1. Upload completed applicant certification form*

Max. file size: 128 MB.