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Critical Needs Repair Loan Program Interest Form
This form has been modified since it was saved. Please review all fields before submitting.
Critical Needs Repair Loan Program Interest Form
Date:
*
Home Owners Name:
*
DOB/Age:
*
Phone Number:
*
Full Address:
*
Housing Unit Information:
*
OWN
RENT (not eligible)
Housing Continued:
*
-- Select One --
Single-Family
Duplex
Condo
3/4 Plex
Multi-Family (not eligible)
Mobile/Manufactured
Year Built:
Total # of People Living In Home:
*
Last Year's Income (all 18+ in home):
*
Current Income (all 18+ in home):
*
Repair(s) Needed (water heater, furnace, roof, sewer, a/c, etc.):
*
Need ADA Modifications:
Yes
No
If Yes, What Type?
-- Select One --
Ramp
Bathroom
Doorways
Other
If Other, Please Explain:
Liens on Property:
*
Yes
No
Bankruptcies in Last 2 Years:
*
Yes
No
Current on Mortgage:
*
Yes
No
Race
-- Select One --
White
Asian
American Indian/Alaskan Native
Black/African American
Native Hawaiian/Pacific Islander
Hispanic
Other
Would you like us to mail you an application?
*
Yes
No
Would you like us to call you to discuss eligibility?
*
Yes
No
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
Submit
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