Home Repair Waitlist Form
Accessibility Statement: If you need reasonable accommodations to complete this form, please contact Nailah Price, (843) 999-1453
Applicant Information
Full Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Birthday
*
-
Month
-
Day
Year
Date
Are you a Veteran?
*
Yes
No
Is anyone that lives in your home a Veteran?
*
Yes
No
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you own or rent your housing?
*
Own
Rent
Do you have an active Homeowners' Insurance Policy?
Yes
No
What specific repairs or issues would you like assistance with?
Please note that filling out this application means you will be added to the waitlist. In the event that additional funding becomes available, we will start from the top of the list and work our way down.
Please verify that you are human
*
How did you hear about us?
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