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The City of Portland, Oregon

Planning and Sustainability

Innovation. Collaboration. Practical Solutions.

Phone: 503-823-7700

Curbside Hotline: 503-823-7202

1900 SW 4th Ave, Suite 7100, Portland, OR 97201

* Required Field

Home Energy Score Income Attestation Form

Attestation Form
e.g. 1120 SW 5TH or 5TH AND MAIN
Do you own the property?
Household Income

In the box below, enter your estimated total household income for the next year. Include all sources of income for ALL residents including wages, overtime, bonuses, tips, unemployment, social security and pension income. Copies of pay stubs and tax returns may be requested to verify income.

The following table will be used to determine program eligibility.

Number of residentsMaximum total household income
1 $36,960
2 $42,240
3 $47,520
4 $52,740

Demographic information (Optional)

We are gathering the following information to understand what populations are being served by this provision. Completing this portion of the form is optional.

Hold Ctrl to select multiple items
Electronic Signature

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In the Pacific Northwest, what state is Portland in?