Home Repair Assistance Questionnaire

Name *

Contact phone number *

Email *

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