Home Solutions of Davidson County's Home Repair Program Form!

Pre-registration Form

for the Home Repair/Accessibility Modification Program
Date and time of submittal

Month Day Year
Date Hour Minutes AM/PM Option
Client/Account Information
Contact person or Referring Agency *
Contact Person's Phone Number *

Area Code Phone Number
Applicant name *
Applicant Phone Number

Area Code Phone Number
Does applicant live in Davidson County, NC? Note: We can only serve residents of Davidson County, NC! *

Yes No
Applicant Street address *
Street address line 2
City *
Zip Code *
E-mail address
E-mail addresses can make the qualification process much easier.
The following questions are required by our office and/or grantors to see if you pre-qualify for this program. Please answer as accurately as possible as applicant will be required to verify all information provided.
Does the applicant live in the home that needs repairs or accessibility modifications? *

Yes No
Does the applicant own multiple properties? *

Yes No
Which best describes the applicants current living situation? *

Rent Rent to Own Owner Co-Owner Estate Owned Lifetime Rights None of the above
Which best describes the type of home *

Wood framed home Manufactured home (mobile, modular, etc.) Apartment/Townhouse/Condo Duplex/Triplex/Multi-family Concrete/Block home Camper or Tiny House
How many people live in this home?
1,2,3, etc.,
Number of adults 18+ living in the home? *
1, 2, 3, etc.,
Marital status of applicant? *

Single Dating Engaged Married Divorced Widowed
Do ANY of the people living in this home meet ANY of these qualifiers? (select as many as applicable) *

Age 62 or older Veteran (regardless of age) Disabled and receiving SSI/SSD benefits Applied for disability but not yet receiving benefits Has 5 or more people living in this home A child 6 or younger lives in this home and the home was built before 1978 Single parent with child living in the home None of these qualifiers apply
You are doing great! We just need a bit more information. The following questions pertain to the household income. It is crucial that you include all income for anyone living in the home as this must be verified.
Check all boxes that apply if ANYONE in the home receives these types of income.

Rental Income Social Security Benefits (SSI or SSD) Retirement/Pension/VA Child Support or Alimony Self-employment Earned wages or salary Monthly assistance from friends or family Monthly assistance programs (food benefits, Work First) Weekly assistance programs (unemployment) This household has ZERO income!
This question may require a little math on your part. How much is the total GROSS HOUSEHOLD income? Remember, GROSS is before any taxes or deductions are taken out and HOUSEHOLD includes everyone in the home. If you are unsure how to figure this then just put 0 (zero) and check yes for the next question. *
Please put a dollar amount!
Do you need help figuring out your total gross household income? *

Yes No
Now please describe the type of repairs or accessibility modifications you are requesting. *

Please be as detailed as possible. 0/400
What is the best timeframe to contact you?

: Hour Minutes AM/PM Option
Until
until : Hour Minutes AM/PM Option
That's it for now! Just hit submit below if you are finished or save to continue later. Thank you for inquiring about our Home Repair Program. Your pre-qualification information will be reviewed as soon as possible and you should receive a response within 3-5 business days. If you need further assistance then please call our office Monday-Friday between 9:00am-5:00pm at 336-236-1675.
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Pre-registration Form