Home Repair Form

First Name

Last Name

Phone

Street Address

City

State

Zip Code

What repairs does your home require?

Are you a home owner or renter?

Home Ownership

Are you current on your mortgage?

Are you current on property taxes, on a payment plan, or have a tax deferral?

Does your home have a septic system?

Are you an honorably discharged veteran, or the surviving spouse of an honorably discharged veteran?

What is your approximate gross income per month?

Does anyone in the home have a physical or mental impairment that substantially limits one or more major life activities?

Do you have any medical records documenting this impairment?