Repair Inquiries

Repair Inquiries

Today's Date*

Applicant Last Name*

Applicant First Name*

Co-Applicant Name

Physical Address*

City*

State*

Select or enter value

Zip Code*

Phone Number*

Phone

Email Address

Applicant Birthdate*

Gender

Select

Do you own the home?*

Yes

No

Do you own the land?*

Yes

No

Type of Home*

Single family detached

Mobile home

Townhouse

Modular Home

Condo

Duplex

What year was the house built?*

Please check the repair needed:*

Accessibility (ramps, handrails, etc.)

HVAC

Electrical

Plumbing

Roof

Exterior (includes doors/windows)

Flooring

Weatherization

Structure

Other

Briefly describe your repair request:*

Has Blue Ridge Habitat worked on your home before?*

Select or enter value

Please enter the year that Blue Ridge Habitat last worked on your home.

Gross Household Income*

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

less than $20,000

$20,000 - $30,000

$30,000 - $40,000

$40,000 - $50,000

$50,000 - $60,000

more than $60,000

Do you have homeowners' insurance?*

Yes

No

# people in household?*

Number of Children under 18*

Is anyone in the household over the age of 60?*

Yes

No

Are you or a member of your household a veteran?*

Yes

No

Branch of Service

Please state which branch was served

Are you the surviving spouse of a veteran?

Yes

No

Are you or a member of your household disabled?*

Yes

No

Race/National Origin

Select

Ethnicity

Select or enter value

Referral Organization:

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