Repair Project Homeowner Intake Form
Please complete this form with as much requested information as possible.
Homeowner
*
Last name, First name
Applicant Birthdate
*
Co-Applicant Name
Co-Applicant Birthday
Address
*
Please enter entire street address, including: City, State & Zip code
Contact Info-Phone
*
Contact Info-Email
Repair Description
*
Please describe the repair(s) needed
Gross Household Income
*
Please estimate your gross household income per month or per year.
House- hold size
Please click total number of people in household
1
2
3
4
5
6
7
8
Children Under 18
1
2
3
4
5
6
Veteran
Click if you or a member of your household is a veteran
Senior (62 & over)
Please click if you or a member of your household is over 62 years old on today's date.
Disabled Family Member
Please click if you or a member of your household is disabled
What is your monthly mortgage payment
Enter 0 if you do not have a mortgage
What is the unpaid balance on your mortgage
Enter 0 if you do not have a mortgage
Homeowners Insurance
Please check if you have homeowners insurance
Manufactured Home
Please indicate if the desired repair is to be performed on a manufactured home.
Yes
No
Reverse Mortgage
Check if you have a reverse mortgage
Year House Was Built
How did you hear about the program
Please click on the arrow to select and option, or enter one if your option is not listed.
Word of mouth
Flyer
Internet search
Habitat website
Radio/TV/Social media
Referred by another program
Neighborhood signs
Other programs applied to
Please enter any other repair programs you have applied to.
Send me a copy of my responses
Email address
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