General Application
Rural Preservation Company of Clinton County
Name
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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
2 digit month, 2 digit day, 4 digit year
Date
Spouse Date of Birth:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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:
Rows
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:
Please upload two months of bank statements and proof of income for all household members, as providing these documents will help speed up the review and processing time.
Browse Files
Cancel
of
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: