• Survey Response Form

    Friends of the North Country, Inc.
  • Do you have a co-applicant?
  • Is mailing address different from property address?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred method of contact:*

  • Housing Information

    Please explain your living situaion.
  • Where do you currently live?*
  • Please explain your type of ownership:*
  • Are the property's land and school taxes paid and up-to-date?*
  • Would you like us to contact you about help with your late taxes?
  • Is the home manufactured or modular housing?*
  • Do you have a mortgage?*
  • Are you up to date on mortgage payments?
  • Would you like us to contact you about help with your mortgage?
  • Are you behind on your rent?*
  • Please select any organizations you are currently receiving help from*

  • Household Information

    Please include yourself and anyone else living in the home.
  • Rows

  • Needs

    Please select what types of assistance you are looking for.
  • Do you have any home repair or replacement needs?*
  • Housing Barriers: which of the following need to be repaired/replaced? (Check all that apply)*
  • Do you or anyone in your home have disabilities that make living at home difficult?*
  • Housing Barriers: what adaptations would allow you or your family member to comfortably and safely remain in the home? (Check all that apply)*
  • Please select any services you have an interest in:*

  • Budget

    If you are interested in having a counselor help you with any of the above affordable housing needs, please complete the budget below. For annual expenses, divide by 12 to get the monthly amount. If you need help, leave it blank and a counselor will call you to discuss.
  • I am in need of housing services and I understand that in order to receive them I must submit an updated budget.*
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Rows
  • Were you able to pursue the referrals given to you at intake?*
  • Would you like a staff member to contact you upon receipt of this form?*
  • Should be Empty: