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. Email Address:
14. Housing Unit Information:*

    1. OWN
    2. RENT (not eligible)
15. Housing Continued:*
    -- Select One --Single-FamilyDuplexCondo3/4 PlexMulti-Family (not eligible)Mobile/Manufactured
16. Year Built:
18. Total # of People Living In Home:*
19. Last Year's Income (all 18+ in home):*
20. Current Income (all 18+ in home):*
22. Repair(s) Needed (water heater, furnace, roof, sewer, a/c, etc.):*
24. Need ADA Modifications:

    1. Yes
    2. No
25. If Yes, What Type?
    -- Select One --RampBathroomDoorwaysOther
26. If Other, Please Explain:
28. Liens on Property:*

    1. Yes
    2. No
29. Bankruptcies in Last 2 Years:*

    1. Yes
    2. No
30. Current on Mortgage:*

    1. Yes
    2. No
31. Race
    -- Select One --WhiteAsianAmerican Indian/Alaskan NativeBlack/African AmericanNative Hawaiian/Pacific IslanderHispanicOther
35. Would you like us to mail you an application?*

    1. Yes
    2. No
36. Would you like us to call you to discuss eligibility?*

    1. Yes
    2. No
Leave This Blank:


38. 1. Receive an email copy of this form.
39. Email address

    This field is not part of the form submission.

40. Submit

* indicates a required field