General Application
Rural Preservation Company of Clinton County
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Email Address:
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone Number
-
Area Code
Phone Number
Cellphone Number
-
Area Code
Phone Number
Head of household Date of Birth:
-
Month
-
Day
Year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
Date
Number of people living in household:
List the ages of others in the household:
Age of your home:
Please answer "yes" or "no" to the following:
Yes
No
Do you have homeowners Insurance?
Are there any liens on your property?
Is this a mobile home?
Do you own the home?
Do you own the property?
Do you have a life lease?
Do you need accessibility modifications for anyone living in the home?
Is anyone in your household a Veteran?
Total Household Income level: Includes income of EVERY person in the home (mark the one your combined income falls below)
$36,200
$41,400
$46,550
$51,700
$55,850
$60,000
Over $60,000
Check off all repairs needed and explain as necessary:
Heating system
Electrical system
Plumbing /septic system
Walls/ceilings/floors
Roof
Chimney
Foundation
Insulation
Lead-based Paint
Other
Please describe the issues you are having in detail below:
I/We certify that all information contained in this application is true and correct
E-signature of head of household
E-signature of Spouse or other adult
Submit
Should be Empty: