Home Repair Work Request

Please use this form to request repair work in your home. You will be required to pay for part of the repair. The amount will be determined by individual circumstances.

Homeowner Name*

Submitted by*

Is This An Emergency?

EMERGENCIES ARE: 1. Total loss of heat (if 40ᵒ Fahrenheit or below for the daily low temperature) – Contact Johansen and Anderson at (815) 723-9385 2. Total loss of air conditioning (if 80ᵒ Fahrenheit or higher for the daily high temperature) – Contact Johansen and Anderson at (815) 723-9385 3. Total loss of electricity – Contact your power company first. If they can’t resolve the problem, then contact JB Electric Service at (815) 693-8403 4. A plumbing leak that requires the entire water supply to be shut off – Contact Reid and Pederson Plumbing at 708-757-9040 5. Total sewage stoppage (ALL toilets and drains) – Contact Reid and Pederson Plumbing at 708-757-9040

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Habitat Owner*

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Adults in House (18 and older)*

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Children in House (under 18)*

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Veteran?

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Senior ? Age

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Referring Party*

Type Of Repair*

Address*

City*

Phone*

Email Address

Notes

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