NRI Screen Form

Neighborhood Revitalization Pre-Screening Application
Date

Month Day Year
TO BE COMPLETED BY THE HOMEOWNER

To apply for assistance all information must be complete and application should be submitted to:

Indian River Habitat for Humanity’s NR Department 4568 N. US Hwy 1 Vero Beach, FL 32967
For questions or assistance please call (772)562-9860 ext. 211 Fax: (772) 562-8732
Forms can be completed online at www.ircHabitat.org
HOMEOWNER INFORMATION
Full Name *

First Name Last Name
Date of Birth *

Month/Day/Year Age
Home Phone Number *

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
CHECK IF HOMEOWNER IS AN INDIAN RIVER HABITAT FOR HUMANITY HOMEOWNER
HOME INFORMATION
Is deed in a name other than listed above? *

Yes No
If Yes, list name:

First Name Last Name
Does homeowner reside in the home? *

Yes No
If Yes, list the length of time
Does home have homeowners insurance? *

Yes No
List Provider
Is home a trailer or mobile home? *

Yes No
Is there a mortgage on the home? *

Yes No
List Monthly Mortgage Amount
What area is home located in? *

Gifford Fellsmere Sebastian Oslo
HOUSEHOLD INFORMATION
Total # of Individuals Living in the home *
# of Adults living in the home
# of Childen (17 or younger) living in the home
Does homeowner(s) have monthly income? *

Yes No
List income for all adults in the household *
Does homeowner receive food stamps? *

Yes No
List Monthly Amount of Food Stamps Received
Does homeowner own any other properties? *

Yes No
Is the homeowner a legal resident? *

Yes No
Are any individuals in the home veterans? *

Yes No
Are any individuals in the home over 65? *

Yes No
Are any individuals in the home disabled? *

Yes No
WILLINGNESS TO PARTNER
Homeowner understands pre-screening applications can take up to 30 business days. Homeowner understands they will be contacted at the number listed on the application for phone interview *

Yes No
Homeowner understands that this is not an emergency or crisis program *

Yes No
Homeowner is willing to partner by completing volunteer hours before repairs are started. Note: alternate options are available for seniors and those who are physically disabled. *

Yes No
Homeowner is willing to partner by paying a down payment of 10% of the total repair cost before repairs are started *

Yes No
Homeowner is willing to partner and pay 70% - 100% of the total repair interest-free loan back in monthly payments over a period of 3 years or less. *

Yes No
SPECIFIC NEED OF HOME REPAIR
Please give a brief description of your critical home repair need
Please give a brief description of your critical home repair need.
REVIEW OF INCOME GUIDELINES

Household Size	Maximum Income
1	$40,900
2	$46,750
3	$52,600
4	$58,400
5	$63,100
6	$67,750

Based on 2021 HUD Data

Check ONLY one: *

I have reviewed the income guidelines and I do not exceed the maximum income limitations. I have reviewed the income guidelines and I do exceed the maximum income limitations.
How did you hear about us? *
CONSENT AND SIGNATURE
I acknowledge that I am responsible and authorized to make decisions about the above property address.

I hereby certify that the information provided herein is true and accurate to the best of my knowledge.

I provide consent and permission for my pre-application to be review for eligibility.

I understand that completing a pre-application is the first step for applying for repairs and does not guarantee acceptance or approval.
Please check the box and type your name below to acknowledge your agreement to the terms and conditions.

I have read and completed the Pre-Screening Form and agree to all terms contained within the form.
Name

First Name Last Name
Should be Empty:

Neighborhood Revitalization Pre-Screening Application

HOMEOWNER INFORMATION

HOME INFORMATION

HOUSEHOLD INFORMATION

WILLINGNESS TO PARTNER

SPECIFIC NEED OF HOME REPAIR

REVIEW OF INCOME GUIDELINES

CONSENT AND SIGNATURE