Home Resilient and Ready Collective Intake Form

HOME REPAIR & SAFETY ASSISTANCE APPLICATION

Thank you for your interest in the PCUL Home Resilient and Ready Collective Program. We’re here to support you. Please complete this pre-screening form to share your home assistance needs and provide some basic information about your household. Assistance is available for eligible applicants, with support of up to $10,000. We look forward to working with you to create a healthier, safer home environment for you, your family, and your neighborhood.
ABOUT THE SERVICES WE PROVIDE

Renovation assistance that PCUL can provide can include: exterior doors and thresholds, solar screening and/or replacement of windows, minor wall repairs, wrapping or replacement of hot water heaters, installation of air ventilation devices, installation of attic insulation, replacement of non-efficient appliances and air conditioning units with smart thermostats, installation of low-flow water devices, and installation of energy-efficient light bulbs.
Please Share Your Home Renovation Needs (You can select multiple)
Which is Of Greatest Concern to You
Do You Need Tree Removal Services?
Do You Need Roof Assistance?
I am interested in learning more about housing services from the City of St. Petersburg
Personal Information
Full Name

First NameLast Name
Gender
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Preferred Language
All Income Before Deductions
What is your total monthly income?
Are You Differently Abled?
Total Number of people living in your residence
Count all household members, including yourself
Ownership Status
Dwelling Type
Name of your Utility Provider
Was your home built before 1978?
Do you have solar?
If not, are you interested in learning more about solar services?
Consent, Authorization, & Disclaimer

read and select each section to agree
I have read, understood, and agree to the terms and conditions outlined below:

Verification & Disclosure AuthorizationI authorize the Pinellas County Urban League (PCUL) and its authorized representatives to verify the information provided in this application. I grant permission to PCUL and its partner agencies to share and collect information necessary to determine my eligibility for assistance. This may include, but is not limited to, income verification, benefits participation, housing status, and contact informationGrant of Access & Limitation of LiabilityI authorize PCUL and its designated contractors, employees, or volunteers to enter my property for the purpose of performing the agreed-upon inspections and/or rehabilitation work. I acknowledge that property improvements and construction work involve inherent risks, including the possibility of unforeseen damage to the property. I understand that external factors, such as severe weather, natural disasters, or pre-existing conditions may impact the results or integrity of the work performed.
Signature
Applicant Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

HOME REPAIR & SAFETY ASSISTANCE APPLICATION

ABOUT THE SERVICES WE PROVIDE

Personal Information

All Income Before Deductions

Consent, Authorization, & Disclaimer

Signature