ACCES and RESTORE - Applicant Program Eligibility Form

Applicant Program Eligibility Form

Please fill out this form to determine your eligibility for the Access to Home programs, and RESTORE program
ApplicantThird party
YesNo
Applicant's Full Name*

First NameLast Name
Select County
Applicant's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Applicant's Date of Birth*

MonthDayYear
Date
Number of people in the household*

Signature & Attestation: By signing I attest that all the information I have provided is true and accurate to the best of my knowledge. *

Clear
You might be eligible for RESTORE Program.

The Residential Emergency Services to Offer (Home) Repairs to the Elderly (RESTORE) program provides financial resources to assist senior citizen homeowners age sixty and over, with the cost of addressing emergencies and code violations that pose a threat to their health and safety or affect the livability of their home. Assistance for the cost of these critical repairs will enable seniors to continue to live independently in their homes.
RESTORE form

You might be eligible for Access to Home Medicaid.

Access to Home for Medicaid Recipients provides financial assistance to make homes accessible for low- and moderate-income people receiving Medicaid and living with a disability, enabling them to live in their residences safely and comfortably. Examples of home accessibility modifications may include wheelchair ramps and lifts, handrails, doorway widening, and roll-in showers.
A2H Medicaid Form

You might be eligible for Access to Home Heroes.

The Access to Home for Heroes/Veterans Program provides financial assistance to make accessibility modifications to the primary residences of low- and moderate-income veterans with disabilities. Such activities will enable veterans with disabilities to live in their residences safely and comfortably, rather than in an institutional setting. Eligible veterans may be renters or homeowners, with service-related injuries, age, or health related disabilities.
A2H Heroes Form

Applicant Program Eligibility Form