Homeowner App

If you are not the homeowner filling out this application, enter your information here. Otherwise, enter Emergency Contact:
First Name: *
Middle Name:
Last Name: *
Mailing Address *:
Mailing City:
Mailing State:
Mailing Zip:
Physical Address *:
Physical City:
Physical State:
Physical Zip:
Home Phone:
Work Phone:
Cell Phone:
Email address:
Alternate Email address:
County:
Ethnicity:
Gender:
Date of birth:
Emergency Name:
Relationship:
Emergency Address:
Emergency City:
Emergency State:
Emergency Zip:
Emergency Home Phone:
Emergency Work Phone:
Emergency 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
General Area Comments:
Application Number:
Are you a previous recipient?	Yes No
Previous Recipient Year:
Program you are applying for:
Best Time to Call:
Other Contact Name:
Other Contact Relationship:
Other Contact Phone:
Other Contact Email:
How did you hear about us?
How you heard about us (if "Other"):
Age:
Disabilities:	Yes No
Please indicate any special needs:
Household Monthly Gross Income:
Are you the head of the household?	Yes No
Percent of Median Income:
Assistance Received	SSI SSDI Food Stamps VA Benefits AFDC Medicare Medicaid Home and Community Based Services
Caseworker Name:
Caseworker Phone:
Other Governmental Assistance
Single or Joint Checking and Savings Account Balance
IRA, 401(k), or similar Account Balance
CD Balance
Stock and Bond Value
Own Other Property (besides the home you live in)?	Yes No
Receive Rent on Other Property?	Yes No
Number of Residents Living in Household (including head of household)

Resident Name	Relationship	Age	SSN	Employed	Disabled	Gender	Ethnicity	Veteran
TPL
0
1
2
3
4

Do residents pay rent?	Yes No
If so, how much?
Do residents have disabilities?	Yes No
Please indicate any special needs:
Have You or Any Other Residents been Convicted of a Felony?	Yes No
If yes, explain:
Number of pets:
What kind of pets?
Do you own your Home or have Tenancy for Life Agreement?	Yes No
Years in Home:
Do you Plan to Sell Home in the Next Year?	Yes No
Do you have Homeowner's Insurance?	Yes No
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:
Are there Tax or Other Liens on Home?	Yes No
Description of Liens:
Neighborhood
Priority Board:
Municipality for Land Tax?
Current Taxes Paid?	Yes No
Recent Repairs/Modifications
How will these repairs/modifications be important to you or help you or your care giver?
Do you have a Personal Caregiver?	Yes No
Something about yourself:
Can Any Family Members Help with Repairs?	Yes No
If no, why not?
Can you get In & Out of Shower with Ease?	Yes No
Can you get to the Bathroom Easily?	Yes No
Can you get On & off Toilet with Ease?	Yes No
Do you have a Bath Mat?	Yes No
Do you have Smoke/Fire/Carbon Monoxide Detectors?	Yes No
Are you a Veteran?	Yes No
Are you Single or Widowed?	Yes No
Home Type: