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BRIDGES REMOVING BARRIERS, ADVANCING AUTONOMY
Dated

MonthDayYear
Date
Applicant Full Legal Name
Date of Birth

MonthDayYear
Date
Primary Residence Address
City
State
Zip Code
County
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Is the applicant a minor, under a guardianship or subject to a power of attorney?

If so, please provide the name and contact information for the applicant's legal guardian and/or POA and include a copy of the relevant legal documentation with this application
Upload guardian documentation (if applicable):

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Guardians name
Guardians email address
example@example.com
Guardian's phone number
Format: (000) 000-0000.
Referred By Agency/Individual
Referral Contact Information if applicable
YesNo
YesNo
YesNo
4) Household Composition & Total Household Income

Eligibility is based on TOTAL household income. Include all household members.
Number of people living in the household including applicant

Type a question

Rows	Name	Relationship to Applicant	DOB	Monthly Income	Income Source
1)
2)
3)
4)

Total Monthly Household Income
Total Annual Household Income
Single-family homeTownhomeCondo / Co-opApartmentOwner-occupied 1–4 unit (applicant lives in one unit)
(If the home is a multi-unit building, repairs may only be made in the unit where the elderly owner resides or in common areas
Year home was built if known
YesNo
YesNo
YesNo
YesNo
Roof leaksPlumbing failuresElectrical hazardsHeating system failureStructural issues (floors, stairs, porch)Mold or moisture issuesUnsafe windows or doorsSeptic/sewer issuesCode-related violations affecting safety
Other repairs/improvements requested:

• Correction of serious structural issues including foundation, floors, doorways, and decksthat provide entry or egress,

• Stabilization, repair, or replacement of damaged or leaking roof and roof vents andgutters,

• Broken, inoperable or unsecured window or exterior door repair or replacement

• Repairs to deteriorated interior or exterior stairs and means of egress,

• Accessibility modifications,

• Repairs of or replacement of failed HVAC systems and chimneys,

• Plumbing repairs or replacement, including correcting issues with potable water supply,domestic hot water, and sewage/septic,

• Mold remediation,

• Electrical repairs or upgrades of electrical/utility systems to remove hazards.
Describe if repairs/improvements requested:
SUPPORTING DOCUMENTATION:

Required for ALL applicants:
State-issued ID for all household members

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Proof of household income for all household members (the most recent tax returns OR paystub OR confirmation of SSI/SSDI benefits received)

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Sign this Notice of Privacy Practices and upload the same below (Right click, print, save as PDF)
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Deed including schedule A:

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Proof of current property taxes being paid:

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Proof of homeowner's insurance

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

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If you have questions or need assistance completing this application, please contact BRIDGES at 845-624-1366.
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