Housing Rehabilitation Program Pre-Application
Interest in Program Funding
Type of property
*
Owner-occupied single family
Owner-occupied (2-4 units)
Not an owner-occupied property
Number of housing units
*
Year the home was built
*
Lead paint: If your home was build prior to 1978, lead paint inspection is mandatory.
Property address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does the property have a different mailing address?
*
Yes
No
Mailing address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Name(s) of property owner(s)
*
Primary phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Primary phone type
*
Please Select
Home
Cell
Work
Secondary phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary phone type
Please Select
Home
Cell
Work
Email address
*
Please double-check for correct spelling. A copy of this completed pre-application will be sent to this email address.
What is your preferred method of communication?
*
Phone
Email
What is your preferred method of receiving application materials?
*
Electronically (via email)
Mail
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Income
Your household and/or the household(s) of your tenants must meet income eligibility requirements. ALL annual gross household income for each resident of the unit is considered. The table below shows the maximum income allowed, per program guidelines.
Number of people in household
*
Estimated combined gross income of all people in household
*
Number of household members over the age of 60
*
Please Select
0
1
2
3
4
5
6
7
8
Number of household members under the age of 6
*
Please Select
0
1
2
3
4
5
6
7
Number of household members with disabilities or accessibility issues
*
Please Select
0
1
2
3
4
5
6
7
8
Is this address your primary residence?
*
Yes
No
If yes, do you live there 6 or more months of the year?
Yes
No
Are you in foreclosure or filing for bankruptcy?
*
Yes
No
Are you up-to-date on all municipal payments (property taxes, water and sewer bills, etc.)?
*
Yes
No
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Housing rehabilitation work required: please select all current and impending problems at the property
*
Rows
Failed system
System will fail within 12 months
Comments/details
Foundation
Heating
Plumbing
Roofing
Doors/windows
Structural
Well
Septic or sewer connection
Wiring
Other (please describe)
If desired, please provide more details about rehabilitation work required at the property.
If you are aware of any other environmental problems or hazards in your home, please describe.
Please attach any written documentation of household health and safety hazards.
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Documents may include, but are not limited to, citations from a board of health, building inspector, fire inspector, sanitarian, engineer, plumber, insurance company, etc.
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Are you on fuel assistance?
*
Yes
No
How did you hear about our program?
*
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Submission
Please sign below and click Submit to complete your application. A copy of your completed application will be sent to the email you provided. You will be contacted as soon as your pre-application has been reviewed.
Homeowner Signature
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