Washington & Burt County Home Repair Loan Interest Form

1

Name* This field is required.

First Name

Middle Name

Last Name

2

Phone Number* This field is required.

Area Code

Phone Number

3

Email* This field is required.

example@example.com

4

Property Type* This field is required.

Property Type

5

What County Do You Live in?* This field is required.

Washington

Burt

Cass

6

Property Address* This field is required.This address must be your primary residence. Our service area includes Omaha and the surrounding communities in Nebraska.

Street Address

Street Address Line 2

City

State

Zip Code

Country

7

Repair Need* This field is required.

Furnace

Water Heater

Air Conditioning

Roofing (Cass County Only)

8

Is your furnace currently working?

YESNO

9

Age of furnace?Please indicate the year your furnace was installed. If you are unsure, please give your best estimate.

Year furnace was installed

10

Is your air conditioner currently working?

YESNO

11

Age of air conditioner?Please indicate the year your A/C was installed. If you are unsure, please give your best estimate.

Year A/C was installed

12

Is your water heater currently working?

YESNO

13

Age of water heater?Please indicate the year your water heater was installed. If you are unsure, please give your best estimate.

Year water heater was installed

14

Do you have an active roof leak?

YESNO