Home Repair Questionnaire

This is a questionnaire, not a final application. This form is to help us determine if the program is right for you. Thank you for your interest in our program.

Homeowner Info

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Cell Phone:

Home Phone:

Email Address:

Please Select if you are applying with a Co-Applicant:

Co-Applicant

Co-Applicant Info

First Name:

Last Name:

Cell Phone:

Email Address:

How many years have you lived in your home?

Is the home 10 years or older?

YesNo

Are you willing to work alongside the Habitat volunteers on your home?

YesNo

In what county do you live?

HenryClaytonFayette

Are you a veteran?

YesNo

Do you own the home you currently live in?

Yes No

How many people live in your home?

Demographic Information (for reporting only)

Are you or someone else in your household handicapped?

YesNo

Ethnicity:

Non-HispanicHispanic

Gender:

MaleFemale

Race:

American Indian or Alaskan NativeBlack or African AmericanNative Hawaiian or other Pacific IslanderWhite or CaucasianMixed Race

Marital Status:

DivorcedMarriedSeparatedSingleWidowed

Expected Household Size

If you are approved you must provide the declaration page of your Homeowners' insurance policy and verify your income.

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Contact Information