Critical Home Repair Program
Inquiry Form
To inquire about having repairs done to your home through our Critical Home Repair Program, please fill out all of the information below. When you hit submit, the form will be sent to our staff for review. You will then be contacted about next steps. If you have any questions, please contact our Director of Affordable Housing, Anngybel Moreta at 978-681-8858 or anngybel@essexcountyhabitat.org. Thank you.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
Marital Status
*
Please Select
Single
Married
Separated/Divorced
Widowed
Gender
*
Please Select
male
female
other
Are you a veteran
*
Please Select
Yes
No
Do you own or rent your home?
*
Please Select
Own
Rent
Type of home
*
Please Select
Single family
Multi family
Mobile home
Number of residents in home
*
Total annual income of ALL residents in home
*
Home built in (year)
*
Referred by
Please fully describe the repair(s) needed:
*
Submit
Should be Empty: