Please select a non-English language for viewing this form, if needed.
Critical Home Repair Application
In which county do you reside?
Monroe
Ontario
Wayne
Monroe County Applicants
Repair applications for Monroe County homeowners are currently closed. You may
join our mailing list
to be notified when they are reopened in the future.
Ontario/Wayne Repair Application
Dear Applicant:
Please complete this application so that we may determine whether you qualify for Greater Rochester Habitat for Humanity's Home Repair program.
Please fill out this application completely
. All information you include on this application will be kept confidential. Please note that incomplete applications cannot be processed.
Scope of Work
Types of repairs needed on your home (select 3 maximum):
Roofing
Windows
Mold Remediation
Entryway
Plumbing
Electrical
Siding
Porch
Accessibility
Error
Primary Contact (if other than Property Owner)
Primary Contact's Name
Primary Contact's Phone
Property Owner Information
First Name
Last Name
Street Address
City
State
Enter 2-letter abbreviation (i.e. NY)
Zip Code
Years at Address
Phone
Phone Type
Home
Mobile
Work
Email
Preferred Contact Method
Email
Phone
Mail
Gender
Please select...
Male
Female
Other
Race
Please select...
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
American Indian AND White
Asian AND White
Black or African American AND White
American Indian AND Black
Other multiple race
I Choose Not to Respond
Unknown
Ethnicity
Please select...
Hispanic
Not Hispanic
I Choose Not to Respond
What is your Date of Birth?
What is your Social Security Number?
Who is on the title for this property?
How many people currently live in the home?
Is
the head of household an adult female with dependents and with no male significant other?
Yes
No
Is anyone in your household a veteran?
Yes
No
Is anyone in your household age 65 or older?
Yes
No
Is anyone in your household disabled?
Yes
No
Do you require a ramp for mobility assistance?
Yes
No
Preferred Language
English
Spanish
Other
Please specify other language
Do you require a translator?
Yes
No
Mortgage Information
Are you making mortgage payments on your home?
Yes
No
What is your monthly payment?
Do not include $ or comma.
Are your mortgage payments current?
Yes
No
Is your homeowner's insurance paid through your mortgage payments?
Yes
No
Are your property taxes paid through your mortgage payments?
Yes
No
Household Anticipated Gross Yearly Income
Income Sources
Employment
Social Security
Social Security Disability
Child Support
Veteran's Benefits
Other
Please specify other income source
Gross
YEARLY
Income (before taxes) - total of all sources of income for the household
I certify that the income reported above represents 100 percent of the total
yearly income for my household.
Yes
Please gather the documents listed below which are required to complete your application. Once all documents are gathered, call our office at (585) 546-1470 to schedule an appointment with a housing counselor. Incomplete packages will not be collected.
Copies of Photo Identification for Property Owner. i.e.: Driver’s License or Passport.
Copies of last 30 days of all household income (includes paystubs, SSI, disability, etc.).
Copy of your monthly mortgage statement if applicable.
Proof of current & active property Insurance (if not paid through your mortgage payment).
Proof of up-to-date property taxes (if not paid through your mortgage payment).
Proof of disability status if applicable.
Proof of veteran status if applicable.
Survey Map of property if applicable.
If you have any questions or concerns, please contact us at (585) 546-1470 during regular business hours (Monday through Friday 9 am to 5 pm).
Contact ID
Property ID
Property Record ID
Repair Record ID
Contact Information