New Hampshire Capital Region Habitat for Humanity Repair Application

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*

MonthDayYear
Date
Prepared By:*

First NameLast Name
Homeowner(s)/Applicants Name*

First NameLast Name
Homeowner(s)/Applicants Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / 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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Should be Empty: