Habitat Home Repair Application

Habitat Home Repair Application

Thank you for your interest in Habitat for Humanity’s Habitat Home Repair Program. Habitat for Humanity promotes dignity and independence for low-income homeowners by addressing critical health and safety needs within their homes. Each family must meet all of Habitat's homeowner selection requirements: 1.) Have a demonstrated need for critical health and safety repairs, 2.) Household gross income must be below 80% of HUD's Area Median Income, 3.) Be willing to partner with Habitat for Humanity, volunteers, and the community in completing repairs on their homes.
Please note that funding for home repairs is limited and is not available in all locations. Habitat's ability to address your need is dependent on funding and project scope. Habitat does not do emergency repairs. Please also note that this is a preliminary interest form - once we receive this application, we will review it and deem eligibility. We will contact you and request additional documents after your submission. Thank you!
Contact Information
Applicant Name*

First Name Last Name
Birth Date*

Month Day Year
Gender*

MaleFemaleNon-Binary
Marital Status:*

SingleMarriedOther
Co-Applicant Name

First Name Last Name
Birth Date

Month Day Year
Marital Status:

SingleMarriedOther
Gender

MaleFemaleNon-Binary
E-mail*
example@example.com
Phone*
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
What type of home do you own?*
What year was your home built?*
How many bedrooms?*
How many bathrooms?*
Is your home in a flood zone?*

YesNoI don't know
For mobile home owners, what is your home's decal number?
For mobile home owners, what is your home's serial number?
Please indicate your critical health and safety needs by checking the boxes that apply.*

ElectricalExterior security lightingFlooringADA compliant kitchen repairGrab barsHandrailsRampwayExterior stairsWindowsDoor wideningOther
Please explain your repair needs below. *
Household income and expenses

Please note that in this application process, you must meet all eligibility requirements, including household income. After submitting this application, you will be requested to submit income verification for all household adults.
Total number of household members currently living in your home*
List of all household members*
Member 2 (Co-Applicant)
Member 3
Member 4
List all other household members and their age:
Total, combined gross income (before taxes) of all persons living in home:*
Does your total household income fall below the income as indicated in the chart below?*

YesNo
Are you still making payments on your home?*

YesNo
Do you have a lien or reverse mortgage on your home?*

YesNo
Is your home in a trust?*

YesNo
Do you have proof of homeownership?*

YesNo
Do you have home insurance?*

YesNo
Additional Information
Are you willing to complete the required sweat equity hours to help repair your home? Sweat equity is your contribution to your home repairs in the form of effort. If you are physically unable, you may have family and friends help you. (Actual hours vary on extent of repairs needed. Single head of household – 8 hours min., dual head of household – 16 hours min.).*

YesNo
Are you a legal resident of the United States?*

YesNo
Are you on active military duty or a veteran?*

YesNo
How did you hear about our program?
I hereby agree that the information given is true, accurate and complete as of the date of this application submission. **

YES
Thank you for your application for a Habitat Home Repair!

Once we have reviewed your application, we will contact you with further instructions. If deemed eligible, we will contact you to submit supplemental documents. If you have any questions in the meantime, please email Jamie Chen, Program Administrator, at jamie@habitatventura.org or call (805) 485-6065 ext. 111. Thank you!
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Habitat Home Repair Application

Contact Information

Household income and expenses

Additional Information

Thank you for your application for a Habitat Home Repair!