Automobiles
Car #1:
Approximate miles driven per year:
Make/Model:
Year:
# Cylinders:
Approximate MPG:
Diesel or Gasoline:Car #2:
Approximate miles driven per year:
Make/Model:
Year:
# Cylinders:
Approximate MPG:
Diesel or Gasoline:

Car #3:
Approximate miles driven per year:
Make/Model:
Year:
# Cylinders:
Approximate MPG:
Diesel or Gasoline:

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Airplane Flights
Approximate total miles or hours flown annually by family members [We want total seat-miles for your family which are in addition to any trips paid for by LBC (these trips the company already pays to make carbon neutral)]:
Total family miles (except LBC) per year:

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Home Energy Consumption
We need your total energy consumption for the entire year for all homes that you occupy. The best would be to total all your bills for the year, but if you don’t have them all handy, then take a typical average monthly bill and multiply by 12. (Note that if you have a second home, you can enter its data below.)Home #1:
Location (city & state):
Months usually occupied:

Electricity: Number of kilowatt-hours consumed per year based on your electricity bill:
Or average kilowatt-hours per month:

Natural Gas: Total natural gas used per year:
in units (name the units on your bill, which may be therms or hundred cubic feet (HCF) or other):
Or average per month:

Heating Oil: Total amount of heating oil used per year (gallons):

Propane: Total amount of propane used per year (units on your bill may be gallons, pounds or kilos):

Wood: Total amount of wood burned per year (may be pounds or cords):

Home #2
[Fill in only if you normally occupy a second home part of the year.]:
Location:
Months usually occupied:

Electricity: Number of kilowatt-hours consumed per year based on your electricity bill: Or average kilowatt-hours per month

Natural Gas: Total natural gas used per year: in units: (name the units on your bill, which may be therms or hundred cubic feet (HCF) or other), Or average per month:

Heating Oil: Total amount of heating oil used per year: gallons

Propane: Total amount of propane used per year: in units: (units on your bill may be gallons, pounds or kilos)

Wood: Total amount of wood burned per year: in units: (may be pounds or cords)
Location (city & state):
Months usually occupied:

Electricity: Number of kilowatt-hours consumed per year based on your electricity bill:
Or average kilowatt-hours per month:

Natural Gas: Total natural gas used per year:
in units (name the units on your bill, which may be therms or hundred cubic feet (HCF) or other):
Or average per month:

Heating Oil: Total amount of heating oil used per year (gallons):

Propane: Total amount of propane used per year (units on your bill may be gallons, pounds or kilos):

Wood: Total amount of wood burned per year (may be pounds or cords):

Additional Information
The following questions will help us suggest how you can reduce your emissions.

Family Size:
Number of Adults:
Number of Children living at home:

Note, if you are not sure of an answer, preferably put in an estimate with a question mark, rather than leaving it blank. For a second home, use another survey form to answer all the questions below.

Home Heating Considerations: (note, please indicate if all temperatures are ºC)
Primary source of heat for your home:
if you ever use additional electric heaters, estimate the total number of hours per year used:

Approximate square footage of your home that is heated and/or cooled (ignore unheated basements or attics):

Average temperature inside your home (thermostat setting) in summer: ºF, in winter: ºF

Do you use a programmable thermostat: , if so, what is the temperature difference when you are at home vs. away from home in the day: ºF, difference at night when you are asleep: ºF

Type of insulation in your attic (can be fiberglass, rock wool, cellulose or foam) thickness units (may be R-value, or inches or cm). Does it have a reflective moisture barrier facing the heated portion:

Type of insulation in your walls: , thickness , units

Type of insulation in your unheated basement ceiling: , thickness , units

Is your basement heated: , if so, what is the type of wall insulation: , thickness , units

Type of heating system, forced air or radiators:

If radiators, aquastat setting: ºF

Manufacturer and model of furnace: , Year , BTUs (if known) ,
Energy efficiency rating (AFUE) (if known):

How often you clean or change the filters on your hot air furnace:

Percentage of double pane glass or storm windows compared to single pane:

Number of doors with double pane glass or storm doors: , number without either:

Percentage of windows and doors that are completely weather-stripped or caulked:

Last time you thoroughly checked your home for air leaks:

Last time you thoroughly checked your heating and cooling ducts for air leaks:

Last time you had a professional energy audit:

Do you have a fireplace: , if so, does it have an airtight damper that is always closed when not in use: , does it have a tight front glass panel so it does not draw out excessive air when in use:
Home Cooling:
Manufacturer and model of air conditioner #1: , Year , BTUs (if known) , Type (central or window) , Seasonal energy efficiency ratio (SEER) for central ACs, or energy efficiency ratio (EER) for window ACs (if known): (For more information on SEER and EER, see http://en.wikipedia.org/wiki/Energy_Efficiency_Ratio)

Manufacturer and model of air conditioner #2: , Year , BTUs (if known) , Type (central or window) , Seasonal energy efficiency ratio (SEER) for central ACs, or energy efficiency ratio (EER) for window ACs (if known):
- Manufacturer and model of air conditioner #3: , Year , BTUs (if known) , Type (central or window) , Seasonal energy efficiency ratio (SEER) for central ACs, or energy efficiency ratio (EER) for window ACs (if known):

Average number of hours per day your air conditioner(s) are on in summer:

How often you clean or change the filters on your air conditioner:

Number of cooling fans in your house that you use regularly:

Percentage of time you use cooling fans instead of air conditioning:

Percentage of your roof that is shaded by trees in the summer:

Do you use a whole house fan for cooling:

Do you have white window shades, drapes, or blinds on south- and west-facing windows and close them during the day in summer and open them in winter:

Do you have awnings to shade south-facing windows?

Do you have sun-control or other reflective films on south-facing windows?

Do you use an attic ventilation fan whenever the temperature is over 80ºF?

Appliances:
Approximate number of light bulbs in your home: Incandescent Fluorescent

Refrigerator #1 manufacturer and model , Year , Size in cubic feet

Refrigerator #2 (if on) manufacturer and model , Year , Size in cubic feet

Separate Freezer (if on) manufacturer and model , Year , Size in cubic feet

How often do you clean the refrigerator and freezer coils:

Clothes Washer manufacturer and model , Year

Usual washing machine setting for white fabrics (hot or warm):

Percentage of the time you use a clothesline instead of a dryer:

Clothes Dryer manufacturer and model , Year gas or electric

Percentage of the time you use clothes moisture sensor, rather than timed drying setting:

Dishwasher manufacturer and model , Year

On average, do you air-dry dishes or use your dishwasher’s heated drying cycle:

Percentage of the time you wash full loads of dishes, rather than partial loads:

Type of stove & oven, gas or electric: , approximate age

If gas, does it have automatic ignition or pilot lights:

Percentage of the time you use a toaster oven instead of a large oven:

Which of your appliances are Energy Star rated (displayed the Energy Star symbol when purchased):(For more information on Energy Star, see: http://www.energystar.gov/)

Type of lawnmower used, electric or gas powered:

Do you always plug home electronics, such as TVs, VCRs, computers, printers, cell phone chargers, etc. into power strips and always turn power strips off when equipment is not in use (at night & when away during the day:

Do you always completely turn off your computer and monitor when you are not using them:

Water Use:
Temperature setting on your hot water heater:

Water heater: manufacturer and model , Year , energy factor (EF) (if known):

What percentage of the time do you take showers instead of baths:

Do you use only low flow showerheads:

Percentage of sinks and washbasins with faucet aerators:

How many gallons per flush do your toilets use (if known) , are they the new water conservation or dual flush toilets:

Do you have a swimming pool: , number of gallons or size and depth: ,
is it heated? , source of heat:

Transportation:
Average number of days per week you drive alone to work:

Average number of days per week you carpool to work:

Average number of days per week you take transit or bike to work:

Average number of days per week you telecommute (work from home):

Consumption/Recycling:
Percentage of bottles and cans you use that you recycle:

Percentage of trash that you put in the recycle bin (so it doesn’t go to landfills):

Percentage of your fruit and vegetable purchases that are organically grown:

Percentage of fruit and vegetable consumption that you grow in your home garden:

Percentage of fruit and vegetable waste that you compost at home: