Refrigerator Replacement Form

Section A

WAP_forms_fridge2010feb12.doc Page 2 of 2

Customer Name:
Service Address:
Phone #: / Alternate Phone #:
Agency Contact Person: / Agency Phone #:

WAP_forms_fridge2010feb12.doc Page 2 of 2

Section B

List unit to be relinquished prior to replacement
Existing Refrigerator Location:

WAP_forms_fridge2010feb12.doc Page 2 of 2

Kitchen: / Utility: / Other: / Floor:
Manufacturer / Model / Type ** / Color
**Types: SS=side-by-side, TF=top freezer, SD=single door, CF=chest freezer, UF=upright freezer

WAP_forms_fridge2010feb12.doc Page 2 of 2

Section C

New Refrigerator

WAP_forms_fridge2010feb12.doc Page 2 of 2

Cubic Feet: / Type**
Door Swing: (please mark only one)
Left Hand / Right Hand

WAP_forms_fridge2010feb12.doc Page 2 of 2

CAUTION: Verify the dimensions of the existing unit and doorways to ensure that the existing unit can be removed from the home and the new unit can be installed in the proper location.

Refrigerator Release

WAP_forms_fridge2010feb12.doc Page 2 of 2

I accept the installation of a new refrigerator provided by (agency)
through the Weatherization Assistance Program. I have been informed that I must release my existing refrigerator prior to receiving a new refrigerator.
Yo acepto la instalación de un nuevo refrigerador proveido por (la agencia)
através del Programa de Climatización. He sido informado que tengo que entregar el refrigerador que estoy usando antes de recibír el refrigerador nuevo.

WAP_forms_fridge2010feb12.doc Page 2 of 2

Client Signature/ Firma del Cliente Date/ Fecha

WAP_forms_fridge2010feb12.doc Page 2 of 2

Replacement Refrigerator Form Directions

Section A

§  Customer Name: Customer’s name as it appears on the Weatherization Application

§  Service Address: Physical Address of the unit (do not write in P.O. Box)

§  Phone#/Alternate Phone#: List phone numbers of the person who owns the refrigerator. (This information will be used to set up a delivery time).

§  Agency Contact: WAP assessor’s name

§  Agency Phone #: WAP Agency’s phone number

Section B

Describe the location of the refrigerator including first or second floor. The installer of the refrigerator will use this section during the delivery of the replacement unit. Provide this information to identify the unit to be replaced.

Section C

List the size and type of the unit that is to be replaced.

List the size of the new refrigerator and the type.

List the door swing direction of the unit that will be replaced.

Client Signature

Notify the client that a refrigerator replacement may only be installed if the existing unit is released.

WAP_forms_fridge2010feb12.doc Page 2 of 2