Home Repair Program Interest List Entry

Today's Date*

Applicant Name*

Applicant Street Address*

Applicant City*

Phone Number*

Email Address

Applicant Family Size*

Applicant Estimated Yearly Income*

Applicant Age

60 or older

59 or younger

Race/Ethnicity

Select or enter value

Have you or any one in the household served, or is currently serving, in the military.*

Yes

No

Do you want to be included in updates surrounding the Home Repair and Accessibility Program Grant ( HRAP) through IHDA and Habitat for Humanity.*

Yes

No

Do you have Roof Repairs

Yes

No

If you selected other, please give more details about the repair.

By typing my name into the box below, I understand that this entry is not an application. I understand that I will be contacted to review my eligibility for Habitat for Humanity's Home Repair Program.*

Send me a copy of my responses