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