First Name (*)

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Address (*)

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Zip Code (*)

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Are you the owner of a single family home? (*)
yesno
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Are you an income earning taxpayer? (*)
yesno
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Do you take any regular measures to limit your impact on the environment? If so give examples.

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Your water heater is .... (*)
electric
gas
on-demand

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Last Name (*)

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City (*)

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Phone Number (*)

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What is your average electric bill? (*)
$100-$149
$150-$199
$200-$300
$300+

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Are you able to make your monthly mortgage payments on time and are you in good standings with your mortgage provider? (*)
yesno
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Do you plan to remain in your home for at least the next 3 years? (*)
yesno
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Which is the best day to contact you?

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