Owner Occupied Property Rehabilitation Pre-Application

Snow Belt Housing

Owner Occupied Property Rehabilitation 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
Do you have a valid deed for the property?

Yes No
Do you currently have a mortgage?

Yes No
Do you currently have homeowner's insurance?

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 aged 18 or younger?

Yes No
Are you a female head of household?

Yes No
Repairs
Please check the boxes for the repairs that may be needed:

Foundation Heating system Plumbing Insulation Roofing/shingle Siding/exterior painting Exterior doors Porches/exterior steps Chimney Electrical Windows Handicap accessibility Other
If other, please list here:
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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Snow Belt Housing