City of Albany Home Repair Program
NYS HCR Targeted Home Improvement Program Application Form
Owner's Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Zip Code - Eligible zip codes are 12202, 12203, 12204, 12206, 12209, 12210
Is this your primary residence?
*
Yes
No
Number of Units
Number of Years Living Here
Number of people living in your household
*
Does anyone live in the home who is:
A veteran
Disabled
N/A
Household Information
*
Rows
Name:First.Last
Gender
Age
Student
Source of Income
Race
Ethnicity
1
Male
Female
Other
Yes
No
Wages
Social Security
Self Employment
Other
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian/Pacific Islander
Two or More Races
Other
Prefer Not to Answer
Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Answer
2
Male
Female
Other
Yes
No
Wages
Social Security
Self Employment
Other
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian/Pacific Islander
Two or More Races
Other
Prefer Not to Answer
Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Answer
3
Male
Female
Other
Yes
No
Wages
Social Security
Self Employment
Other
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian/Pacific Islander
Two or More Races
Other
Prefer Not to Answer
Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Answer
4
Male
Female
Other
Yes
No
Wages
Social Security
Self Employment
Other
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian/Pacific Islander
Two or More Races
Other
Prefer Not to Answer
Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Answer
5
Male
Female
Other
Yes
No
Wages
Social Security
Self Employment
Other
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian/Pacific Islander
Two or More Races
Other
Prefer Not to Answer
Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Answer
6
Male
Female
Other
Yes
No
Wages
Social Security
Self Employment
Other
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian/Pacific Islander
Two or More Races
Other
Prefer Not to Answer
Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Answer
7
Male
Female
Other
Yes
No
Wages
Social Security
Self Employment
Other
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian/Pacific Islander
Two or More Races
Other
Prefer Not to Answer
Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Answer
8
Male
Female
Other
Yes
No
Wages
Social Security
Self Employment
Other
American Indian/Alaska Native
Asian
Black/African American
White
Native Hawaiian/Pacific Islander
Two or More Races
Other
Prefer Not to Answer
Hispanic/Latino
Not Hispanic/Latino
Prefer Not to Answer
Please upload Proof of Income (hover for details)
Browse Files
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Please Describe Desired Repair Work
Upload the following: 1) Most recent utility bill (all pages); 2) Current Homeowners Insurance Declaration Page; 3) Most recent bank statements; 4) Picture ID with current address (hover for details)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Applicant's Signature
*
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: