Repair Inquiries

Today's Date

Applicant Last Name

Applicant First Name

Co-Applicant Name

Physical Address

City

State

Zip Code

Phone Number

Phone

Email Address

Applicant Birthdate

Gender

Do you own the home?

Yes

Do you own the land?

Yes

What year was the house built?

Briefly describe your repair request:

Has Blue Ridge Habitat worked on your home before?

Gross Household Income

Please estimate your gross household income per year. (Include income from everyone in the home over 18.)

Do you have homeowners' insurance?

Yes

# people in household?

Number of Children under 18

Is anyone in the household over the age of 60?

Yes

Are you or a member of your household a veteran?

Yes

Are you or a member of your household disabled?

Yes

Race/National Origin

Ethnicity

Referral Organization: