HOME Program Pre-Screening Form

HOME Program Pre-Screening Form

County of Greene
Applicant Name*

First NameLast Name
Date of Birth*
Co-Applicant Name

First NameLast Name
Co-Applicant Date of Birth
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from physical address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Please answer each question to complete the HOME Program Pre-Screen. Once the pre-screen has been completed, program staff will contact you regarding eligibility and further instructions.
Do you own the home in which you reside?*

YesNo
If yes, please upload the Deed to your home

Browse Files
Deed Cancelof
If you answered no to Question 1, please explain below:
NOTE: The Greene County HOME Program WILL NOT consider rent-to-own properties or homes that are not owned by the applicant(s). This program is meant for Owner Occupied Housing Units. If you have a rent-to-own property or do not own your land, please contact the office at homeprogram@co.greene.pa.us or 724-852-5260 for further information.
Is the home located in Greene County?*

YesNo
Is this property a mobile home? Mobile homes may be eligible for this program if they are on a permanent foundation and the applicant(s) own the land in which the home is located. A valid mobile home title and a deed are required to verify ownership.*

Yes, on a permanent foundationYes, not on a permanent foundationNo
If yes, please upload the Mobile Home Title

Browse Files
Title to Mobile Home Cancelof
Is there a mortgage on the property?*

YesNo
If yes, what is outstanding balance on the principle amount?
NOTE: Applicant(s) who have a mortgage filed on their residence/ property will be required to submit verification of the filed mortgage.
How many people reside in the home (including minor children)? If there is a shared custody arrangement, please only county children who live in the home at least 51% of the year*
Is anyone in the home over the age of 62?*

YesNoNo, but someone will turn 62 in the next 6 months
Is anyone Disabled?*

YesNo
Is anyone a Veteran?*

YesNo
Is the Head of Household:*

DisabledFemaleOver the age of 62
Are there any children under the age of 18 that live in the home at least 51% of the year?*

Yes 0-5 years oldYes 5- 17 years oldNo
Race and Ethnicity (select all that apply)*

White CaucasianBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderHispanicNot Hispanic
Have you received any funding from another Greene County Assistance Program in the last 5 years?*

NoYes
If Yes, Please give the name of the Program as well as the month and year you received assistance.
If you have any current code violations within your township, please upload them here.

Browse Files
Township citations, notices, etc. Cancelof
Do you have any assets? If applicable, please list the asset(s) and associated value(s) below.*
NOTE: Assets do NOT include your home or everyday vehicle.

Please list the TOTAL monthly gross (pre-tax) income for all household members*

	Wages/Salaries	Benefits/Pensions	Public_Assistance	Other_Income
Head of Household
Other Members

What is your approximate gross (pre-tax) monthly income from all sources? If there are more sources of income then please describe them in "Other".*
Please use the space below to describe monthly income if the income source was not listed above:
Please upload income verification for all applicants and all household members:*

Browse Files
Social Security Statement, W2s, 1099s, Pension, Retirement, Paystubs, etc. Cancelof

17. Family Composition

	Household_Member_Full_Name	Relationship_ to_Head_of_Household	Date_of_Birth	Age
Head of Household
2
3
4
5
6
7
8

Please list any other members below:
Pre-Screen Housing Questionnaire
Number of Bedrooms? bedrooms
Number of Bathrooms?   bathrooms
What year was the home constructed?   construction year
Do you have an attic?   attic
Do you have a basement?   basement
What type of heat source?    heat source
Has your roof been replaced in the past 10 years, when?   roof
Do you have an attached garage?   garage
Do you have a sump pump?   sump pump
Where is your hot water tank?   water tank
Where is your breaker box?   breaker box
How many decks/perches do you have?   decks/porches
The Exterior of your home is:

BrickAluminum SidingVinyl SidingWood SidingStuccoMultiple
If you need to explain, do so here
REPAIRS NEEDED

Please list any repairs that you need in the following areas of your home.
Kitchen
Bathrooms
Bedrooms
Living Room
Exterior
If any other repairs are needed, list them here. *
Include any ADA accessibility options you may need here as well.
PLEASE REVIEW ALL INFORMATION SUBMITTED FOR ACCURACY

The HOME Program process requires you to provide documentation verifying ownership of property/residence, all income for the household, mortgage, tax information, bank statements, and homeowners' insurance.

If an applicant wishes to continue with the process after the pre-screening, at the discretion of HOME Program Staff, they will be required to submit verification of the above stated from the source.
By signing below, I/ we certify that all information in this HOME Program pre-screen is accurate.

The HOME Program is pausing applications as of 12/20/2022. All interested applicants who complete the pre-screening form will be notified of initial eligibility and placed on an "Interested Applicants" List in the order of which they were recieved. Once applications are open again, the pre-screened individuals will be notified and sent an application.
Signature

Clear
Date
If you have any questions or concerns, please contact our office via email:

homeprogram@co.greene.pa.us

Or call our office at 724-852-5260.

Ginny Phillips, HOME Program Manager

Nicole Mickens, RDA Director
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HOME Program Pre-Screening Form

Pre-Screen Housing Questionnaire