Home Repair Assistance Questionnaire

If you have any questions please contact 501-371-6825

Please click link for the PDF version of the Questionnaire 

Home Repair Assistance Questionnaire Form

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Name *

Contact phone number *

Email *

home? Electrical, currently

Applicant's full address *

Age of applicant *

Applicant income *

Number of persons in household *

Race *

Gender *

Year house was built? *

Number of bedrooms? *

Number of bathrooms? *

Is the applicant Disabled? *

• Yes
• No

Does applicant own their home? *

• Yes
• No

Does applicant have insurance? *

• Yes
• No

Are you currently in Environmental Court for housing code violations? *

• Yes
• No

Type of Assistance Requested: (Roof, Plumbing, Electrical, HVAC, World Changers)

Consent for storing submitted data *

• Yes, I give permission to store and process my data
• No, I don’t consent to storing and processing my data

Submit