Snow Belt Housing
Mobile Home Replacement Pre-Application
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: