Home Repair Inquiry Form

First Name

Last name

Phone Number

Phone

How did you hear about our repair program?

Address

City

State

What neighborhood do you live in?

Is anyone living in the home a veteran?

Yes

Alternate Contact: name, phone number, relation

Is anyone in your home 60 years or older?

Yes

Do you or someone in the home have a disability?

Yes

Are you the homeowner?

Yes

Is this a Habitat House?

Yes

What are your home repair needs?

Do you have code violations? (Letters from IPL?)

Yes

Do you have a Mortgage?

Yes

Monthly Income

Total number of people in the household

How long have you had this issue with your home??

Do you have home insurance?

Yes

Are you current on your property taxes?

Yes

Comments

Please upload a copy of your Driver's license or ID, income verification, or any award letters.

Uploading these documents will help us apply for grants to complete your home repairs faster, if you are accepted into our program.

Drop your files here

Send me a copy of my responses