New Hampshire Capital Region Habitat for Humanity Repair Application
2024: Please fill out all questions. Please add copies of all documents either in this application, via email, or through mail.
Date
*
-
Month
-
Day
Year
Date
Prepared By:
*
First Name
Last Name
Homeowner(s)/Applicants Name
*
First Name
Last Name
Homeowner(s)/Applicants Name
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Best Time to Contact You:
*
Describe the problem that you would like to have repaired:
*
Total Number of Persons in the Household:
*
Number of Adults
*
Number of Dependents (N/A if not applicable)
*
Names and Ages of Dependents in the Household (N/A if not applicable):
Names of Adults in the Household and their Individual sources of Income (Ex. John Doe, Self-Employed):
*
Household Annual Income (Include Social Security, Disability, Child Support, etc.):
*
Total Financial Assets
*
Includes all accounts (Checking, Savings) Excludes retirement.
Ways in which you can help with the project (financial and/or sweat equity)
*
Any additional information that you would like Habitat to know when considering this application?
Proof of Income (ONE of the following - Federal Tax Return first page for last year {IRS Adjusted Gross Income}, Income verification for the past four weeks {i.e., pension, social security, disability, unemployment, child support, etc.} for each adult household member with a regular source of income, or those who receive Social Security as sole income should obtain a document showing last year's Social Security income total.
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Proof of Homeownership (ONE of the following: Property Deed, Mortgage bill, Property tax bill showing your name and address of the property)
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Proof of Homeowner's Insurance:
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