Mobile Home Replacement Pre-Application

Snow Belt Housing

Mobile Home Replacement Pre-Application
Name

First Name Last Name
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

City County

Postal / Zip Code
Have you owned and lived in the home for at least (1) year?

Yes No
Does your home have any current mortgages and/or liens?

Yes No
Do you have a valid deed for the property?

Yes No
Are your current property tax bills paid?

Yes No
Are you able to provide receipts?

Yes No
Is there current insurance on the property?

Yes No
Are you able to provide proof?

Yes No
Have you ever used grant funds to repair your home in the past?

Yes No
If yes, what was repaired and when?
Tenant info
Names of all household members that contribute to income:
Source of income for each household member:
Total monthly income for each tenant:
What is the total yearly income for everyone in the household?
How many people live in the household?
Is anyone age 60 or over?

Yes No
Is anyone disabled?

Yes No
Is anyone handicapped?

Yes No
Are you a single parent with children 18 or younger?

Yes No
Are you a female head of household?

Yes No
Home Assessment

Please check the condition of each item below
Foundation type:
Foundation condition:

Good Fair Poor
Roofing type:
Roofing condition:

Good Fair Poor
Siding type:
Siding condition:

Good Fair Poor
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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