Untitled document Thank you for your interest!

* - Required field.
*First name
Middle name
*Last name
Mailing Address 1
Mailing Address 2
Mailing City
Mailing State
Mailing Zip code
Physical Address 1
Physical Address 2
Physical City
Physical State
Physical Zip code
Home phone
Work phone
Work phone ext.
Cell phone
E-mail address
County
Ethnicity
Gender
Date of birth
If you are not the homeowner filling out this application, enter information here.

Otherwise, enter emergency contact.
Name
Relationship
Address
City
State
Zip code
Home phone
Work phone
Work phone ext.
Cell phone
Application date
General Areas ADA
Appliances
Carpentry
Concrete
Doors
Electrical
Energy
Exterior Paint
Flooring
Furnace
Grab Bars/Handrails
Gutters
Hot Water Heater
Locks
Other
Plumbing
Roof
Ramp
Safety
Stairway/Porch
Trash Removal
Tub/Tile
Wall Repair/Paint
Windows
Yard Work

Comments:
Previous Recipient
Year:
Best Time To Call
Other Contact Name
Other Contact Relationship
Other Contact Phone
Other Contact Email
Hear About
Age
Disabilities
Please indicate any special needs:
Household Monthly Gross Income
Assistance Received SSI
SSDI
Food Stamps
VA Benefits
AFDC
Medicare
Medicaid
Home and Community Based Services
Caseworker Name
Caseworker Phone
Other Governmental Assistance
Own Other Property (besides the home you live in)?
Receive Rent on Other Property?
Residents Living in Household (including head of household)
Name Relationship Age SSN Employed Disabled Gender Ethnicity Veteran
Residents Pay Rent?
If yes, how much?
Any Residents have Disabilities?
Please indicate any special needs:
You or Any Other Residents been Convicted of a Felony?
If yes, explain:
Number of Pets
What kind?
Own your Home or have Tenancy for Life Agreement?
Years in Home
Plan to Sell Home in the Next Year?
Homeowners Insurance?
If no, please explain. If yes, include Insurance Company & policy number:
Number of Bedrooms
Number of Bathrooms
Number of Living Rooms
Number of Other Rooms
Tax or Other Liens on Home?
Description:
Current Taxes Paid?
Recent Repairs/Modifications
How will these repairs/modifications be important to you or help you or your care giver?
Personal Caregiver
Something About Yourself...
Any Family Members Help with Repairs?
If no, why not?
In & Out Shower with Ease
Get to Bathroom Easily
On & Off Toilet with Ease
Smoke/Fire/Monoxide Detectors
Veteran?
Single/Widowed?
Home Type