DignityBath Property Assessment Form
Are you a Veteran qualified for a SAH grant?
YES
NO
Live on first floor of this Single-Family Home
YES
NO
My e-mail address is
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Property Location
Street Address
City
ZIP
Property Description
Single Family Home
Mobile Home
Rental
Bedroom on First Floor
Height of First Story above Ground Level
Must Be 60 inches or Below
Lot Characteristics
Flat
Gentle Slope
Heavy Slope
Is the Home currently in Compliance with ALL Local Code Regulations, including utilities?
YES
NO
Property Owner
Veteran
YES
NO
Permission for On-Site Assessment?
YES
NO
________ FOR VETERANS ONLY ________________
If the Property is not owned by the Veteran who is the Property Owner?
Property Owner
Relation to Veteran
Name of Applicant
Permission for On-Site Assessment?
YES
NO
If you are a SAH Grantee do you wish to place one of the two SAH stipulated ramps at the exterior door of the DignityBath into the Corridor?
YES
NO
Submit
Should be Empty: