PRELIMINARY HOMEOWNER APPLICATION

NAME OF PRIMARY APPLICANT*

First NameLast Name
AGE*
NAME OF SECONDARY APPLICANT

First NameLast Name
AGE
HOME ADDRESS*

Street Address

CityState / Province

Postal / Zip Code
CONTACT PHONE NUMBER*
Please enter a valid phone number.
EMAIL
example@example.com
BEST TIME TO REACH YOU

MORNINGAFTERNOONEVENING
DO YOU OWN YOUR HOME?

YESNO
ARE YOU A SENIOR CITIZEN?

YESNO
ARE YOU A VETERAN?

YESNO
IS ANYONE IN THE HOUSEHOLD DISABLED?

YESNO
NUMBER OF ADULTS LIVING IN THE HOME?*
NUMBER OF MINOR CHILDREN LIVING IN THE HOME?*
ANNUAL HOUSEHOLD GROSS INCOME*
BRIEFLY, PLEASE LET US KNOW HOW WE CAN HELP?
BY SIGNING BELOW, I/WE CERTIFY THAT ALL INFORMATION PROVIDED ON THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY/OUR KNOWLEDGE. I/WE AUTHORIZE THE CHECKING OF ANY REFERENCES NECESSARY TO COMPLETE THE PROCESSING OF THIS PRELIMINARY APPLICATION FOR THE PURPOSE OF POTENTIALLY RECEIVING HOME REPAIRS THROUGH RTSGVF. FALSE INFORMATION MAY RESULT IN DISQUALIFICATION.
PRIMARY APPLICANT SIGNATURE*

Clear
DATE*

MonthDayYear
Date
SECONDARY APPLICANT SIGNATURE

Clear
DATE

MonthDayYear
Date
Should be Empty: