OFFICIAL USE ONLY
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____ Application received by Tribal Home Repair Program
Date Received: ______________ Initial ______
____ Application forwarded to Dept. of Housing
Date Received: ______________ Initial ______
Action taken by Dept. of Housing:
ELIGIBLE FOR MEPA FUNDS: YES/NO
ELGIBLE CHG BK AGMT: YES/NO
Dept. of HOUSING
TO PERFORM EMERGENCY REPAIRS: YES/NO
FWD TO Tribal Home Repair: YES/NO