Green Mountain Home Repair Inquiry Form

Applicant information

Provide details for the Primary Applicant below. The Primary Applicant will be the main contact. It is not required that the Primary Applicant be the most significant contributor to the family income. If there is a Co-Applicant, another household member that will be a co-borrower or co-owner, please include their details also.

First Name

Last Name

Email Address

If you don’t have an email, please enter noemail@noemail.com.

Home Phone

Please use this format: 555-555-5555

Preferred Phone

Mobile Phone

Please use this format: 555-555-5555

Work Phone

Please use this format: 555-555-5555

Preferred method of contact

Phone callPhone textEmail

Applicant Mailing Address

Street Address

City

State

Zip Code

County

Is there a co-applicant?

YesNo

Co-Applicant information

First name

Last name

Email address

Phone number

Please use this format: 555-555-5555

Preferred method of contact

Phone callPhone textEmail

Is co-applicant's address the same as applicant?

YesNo

Co-Applicant Mailing Address

Street Address

City

State

Zip Code

County

Household Type

Number of Other Household Members (not including the applicant nor the co-applicant)

Gross Annual Household Income

Please list your household's annual gross income including all sources from all family members.

Is the street address of the property for rehabilitation the same as the applicant's address?

YesNo

Street Address of Property for Rehabilitation

Street Address

City

State

Zip Code

County

Home Repair Needs Summary

How did you hear about the program?

Contact Information