Snow Belt Housing
Property Rehabilitation Pre-Application
Name
First Name
Last Name
Email
example@example.com
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?
Household 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
Submit
Should be Empty:
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