Thank you for your interest in Clark Public Utilities’ Limited Income Smart Thermostat Program. For your home to be eligible it must be a single family or manufactured home (not a multi-family property with 4 or more units) and heated by a properly functioning heat pump (not ductless heat pump) or electric forced air furnace as the primary heat source. Homes with natural gas heating are not eligible. Household eligibility is based on total household gross income and the person applying for the program must be listed on the Clark Public Utilities account.If you feel your household qualifies, please fill out the form below: Do you rent or own your home?Home owners and renters can both qualify for the program. If you are a renter we will also require a copy of your rental agreement along with a pre-signed form from your landlord authorizing the Nest thermostat installation. The installer will provide the necessary form for signature prior to your appointment and gather the needed items at your installation appointment.I rent my homeI own my homeWhat type of home do you live in?Single FamilyManufacturedMulti-Family (more than 4 attached units)What is your home's primary heating fuel?ElectricGasOtherWhat's your home's heating system?Forced Air FurnaceHeat Pump (Ducted)Zonal: Baseboard, wall heaters, ceiling radient, etcDuctless Heat PumpAlready have Nest or EcoBee Thermostat?YesNoIncome InformationHow many people live in your household?12345678910More than 11What is the household gross monthly income?Do you pay any child or spousal support?YesNoDo you pay any child or spousal support?YesNoDo you pay any child or spousal support?YesNoDo you pay any child or spousal support?YesNoDo you pay any child or spousal support?YesNoDo you pay any child or spousal support?YesNoDo you pay any child or spousal support?YesNoDo you pay any child or spousal support?YesNoDo you pay any child or spousal support?YesNoDo you pay any child or spousal support?YesNoPayment Type 1Monthly Payment Amount 1Payment Type 2Monthly Payment Amount 2Payment Type 3Monthly Payment Amount 3Total AmountQualify BinaryPlease list income I declare total household income from the last 3 months was:Month 1*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberIncome Amount 1*Month 2*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberIncome Amount 2*Month 3*JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberIncome Amount 3*That income was from the following sources:Use the + button to add another source. We need more information to determine your eligibility.We’re sorry but based on the information provided, you do not qualify for this program. To learn more about our other rebate programs, click here. To learn more about other Energy Assistance programs, click here.Contact InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Account NumberBased on the information entered, you are eligible "I certify that the information contained above is complete and accurate to the best of my knowledge. I understand that I am signing this statement under penalty of prosecution if I knowingly give false information, which results in assistance received for which I am not eligible."Signature*Date* Date Format: MM slash DD slash YYYY This iframe contains the logic required to handle Ajax powered Gravity Forms.