Emergency Home Repair Service Request

Emergency Home Repair Service Request

First Name*

Last Name*

Address*

Phone (Primary Contact #)*

Phone

Do you own your property?*

Yes

Are you over 65?*

Yes

Are you on Medicaid or Medicare?*

Yes

Do you have homeowner's insurance?*

Yes

What type of service are you applying for?*

Select

Please read the following and select Yes or No.*

I am the owner of the property subject to this request. I hereby authorize the City of Garland, its employees, agents, and subcontractors to enter upon my property for the purpose of performing repairs requested as deemed necessary by the City. I further authorize the City to undertake all actions it deems necessary to complete the repairs, including the use of machinery, equipment, and materials. I hereby release, discharge, and waive any and all claims against the City of Garland, its employees, agents, and subcontractors for any damages or liability arising out of or in connection with the entry or repair activities conducted on the property. This authorization shall remain in effect until the completion of the repairs as determined by the City of Garland. By clicking below, I acknowledge that I have read, understood, and agree to the terms and conditions set forth in this authorization.

Yes

File Upload*

Please upload the required documentation:

Drivers License or other legal ID

Medicaid/Medicare card (if you are a senior or disabled and receive Medicaid/Medicare)

Drag and drop files here or

Send me a copy of my responses

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