Minor Home / Emergency Repair Pre-Application

2. APPLICANT INFORMATION

4. Date
   Date

5. Tax Parcel Number*

6. Referred by

8. Last Name

9. First Name

10. Middle Initial

12. Last 4 of SSN

13. Date of Birth
    Date of Birth

14. Gender

    1. Male
    2. Female

16. E-Mail Address

18. Marital Status

    1. Single
    2. Married

    1. Unmarried
    2. Divorced

    1. Widow / Widower
    2. Living Together

20. Race

21. Hispanic

    1. Yes
    2. No

22. Primary Language Spoken

23. Mobile Home Park Name

25. Street Address

26. City

27. Zip Code

29. Mailing Address

30. City

31. Zip Code

33. Move-In Date
    Move-In Date

34. Home Phone Number

35. Other Phone Number

37. OTHER HOUSEHOLD MEMBERS (list everyone who lives in the home or on the property)

41. Name

42. Last 4 SSN

43. Date of Birth
    Date of Birth

45. Relationship

46. Race

47. Hispanic

    1. Yes
    2. No

51. Name

52. Last 4 SSN

53. Date of Birth
    Date of Birth

55. Relationship

56. Race

57. Hispanic

    1. Yes
    2. No

61. Name

62. Last 4 SSN

63. Date of Birth
    Date of Birth

65. Relationship

66. Race

67. Hispanic

    1. Yes
    2. No

71. Name

72. Last 4 SSN

73. Date of Birth
    Date of Birth

75. Relationship

76. Race

77. Hispanic

    1. Yes
    2. No

81. Name

82. Last 4 SSN

83. Date of Birth
    Date of Birth

85. Relationship

86. Race

87. Hispanic

    1. Yes
    2. No

91. Name

92. Last 4 SSN

93. Date of Birth
    Date of Birth

95. Relationship

96. Race

97. Hispanic

    1. Yes
    2. No

101. HOUSING INFORMATION

103. House Type

     1. Mobile
     2. House

     1. Condo
     2. Duplex

104. House Status

     1. Own Home & Land
     2. Rent

     1. Own Mobile/Rent Space

106. Heat Method

     1. Electric
     2. Oil
     3. Natural Gas

     1. Wood
     2. Propane
     3. Other

107. Heat System

     1. Radiant
     2. Baseboard
     3. Forced Air

     1. Stand Alone
     2. Wood Stove
     3. Heat Pump

109. INCOME INFORMATION (for every person who lives in the home or on the property)

111. Name

112. Source

113. Frequency

114. Amount

116. Name

117. Source

118. Frequency

119. Amount

121. Name

122. Source

123. Frequency

124. Amount

126. Name

127. Source

128. Frequency

129. Amount

131. ASSET INFORMATION (for every person who lives in the home or on the property)

133. Type

134. Amount

135. Name

137. Type

138. Amount

139. Name

141. Type

142. Amount

143. Name

145. Type

146. Amount

147. Name

149. Type

150. Amount

151. Name

153. Type

154. Amount

155. Name

157. IMPAIRMENT INFORMATION (for every person who lives in the home or on the property)

159. Name

160. Impairment(s)

161. Name

162. Impairment(s)

164. Name

165. Impairment(s)

166. Name

167. Impairment(s)

169. Name

170. Impairment(s)

171. Name

172. Impairment(s)

174. REPAIRS NEEDED

176. ADDITIONAL COMMENTS

178. After you click Submit, please allow a few seconds for your request to process, at which time you will be redirected to a confirmation page. Do not click Submit again.

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180. 1. Receive an email copy of this form.
181. Email address

     This field is not part of the form submission.

182. Submit

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