Critical Needs Repair Loan Program Interest Form

2. 

3. Critical Needs Repair Loan Program Interest Form

5. Date:*

6. Home Owners Name:*

7. DOB/Age:*

8. Phone Number:*

10. Full Address:*

12. Housing Unit Information:*

    1. OWN
    2. RENT (not eligible)

13. Housing Continued:*
    -- Select One --Single-FamilyDuplexCondo3/4 PlexMulti-Family (not eligible)Mobile/Manufactured

14. Year Built:

16. Total # of People Living In Home:*

17. Last Year's Income (all 18+ in home):*

18. Current Income (all 18+ in home):*

20. Repair(s) Needed (water heater, furnace, roof, sewer, a/c, etc.):*

22. Need ADA Modifications:

    1. Yes
    2. No

23. If Yes, What Type?
    -- Select One --RampBathroomDoorwaysOther

24. If Other, Please Explain:

26. Liens on Property:*

    1. Yes
    2. No

27. Bankruptcies in Last 2 Years:*

    1. Yes
    2. No

28. Current on Mortgage:*

    1. Yes
    2. No

29. Race
    -- Select One --WhiteAsianAmerican Indian/Alaskan NativeBlack/African AmericanNative Hawaiian/Pacific IslanderHispanicOther

33. Would you like us to mail you an application?*

    1. Yes
    2. No

34. Would you like us to call you to discuss eligibility?*

    1. Yes
    2. No

Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field