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Fitzgerald Home Repair Request Form
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1
Disclosure Statement
*
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For your home to qualify for home repairs, it must be located within the following boundaries: W. McNichols (north), Puritan (south), Livernois (east), and Greenlawn (west). Repair work will exclusively focus on the exterior of the home which will include windows, roofs, porches, gutters, and exterior doors. Repairs pertaining to furnaces, plumbing, or interior renovations such as kitchen, bathroom, drywall, and flooring are not included in this project. This is a one-time project, with all repairs scheduled for completion by December 31, 2024. Given the limited funding for this pilot project, priority will be given based on need, particularly focusing on seniors, individuals with disabilities, or those requiring special accommodations. The data collected will contribute towards the decision-making process. This application will open May 13th, 2024 and will close June 10, 2024. All fields marked with (*) are required and must be filled out for eligibility consideration.
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2
Full Name
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First Name
Last Name
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3
Date of Birth
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Month
Day
Year
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4
Home Address
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Street Address
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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5
City and State
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6
Zip Code
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7
Phone Number
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8
E-mail
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example@example.com
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9
Describe your employment status:
*
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Employed
Student
Unemployed
Retired
Disabled
Other
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10
Ethnicity
*
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Please select one or more below
Black/African American
Asian
American Indian/Alaskan Native
Native Hawaiian/Other Pacific Islander
White
Other
Hispanic or Latino
Not Hispanic or Latino
Other
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11
Preferred Method of Contact
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Text Message
Phone Call
Email
In-Person
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12
Best Time To Call
*
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Morning
Noon
Evening
Other
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13
Provide Parcel ID Number
*
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To find your parcel ID Number, please use this website:
https://detroitmi.gov/webapp/city-detroit-parcel-viewer
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14
Do you own your home?
*
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Yes
No
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15
Upload Proof of Ownership
*
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Upload one piece of ownership for example Title Deed, Property Tax Receipts, Mortgage Payment Records)
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Max. file size
: 10.6MB
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16
Upload Proof of Occupancy
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(Current utility bill, insurance certificate, homestead exemption)
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17
Upload Proof of Property Tax
*
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Provide proof that you are up to date on your most recent city and county property taxes by uploading recent proof of payment.
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: 10.6MB
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18
How long have you lived in this home?
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19
Of the repairs listed, which repair do you deem as priority?
*
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Pick One
Roof
Porch
Gutter
Window
Exterior Door
Other
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20
Please upload photos of the specific area in your home where you're requesting for repair.
*
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Max. file size
: 10.6MB
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21
Have you received home repair assistance before?
*
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Yes
No
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22
Please provide a list of all organizations who have assisted with previous home repairs.
*
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List Below
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23
How many people live in your home?
*
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24
Is your quality of life impacted due to the need for a home repair? If so, please describe
*
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25
Can we send someone from our team to your home to assess the areas needed for repair?
*
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Yes
No
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26
May we contact you for more information?
*
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Yes
No
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27
Is there anything else that we should know?
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