Submit Repair Application

Application Type

Application Status

Funding Program

Application Current Status

Denied Reason

Incomplete Reason

Denied Notes

Application Dates

Received Date

Denied Date

Incomplete Date

In Scope Date

In Process Date

Closed Pending Date

Completed Date

Applicant Information

First Name

Middle Initial

Last Name

SSN

Birthdate

Phone 1

Phone 2

Homeowner Email

Marital Status

Contact Notes

Applicant Address

Apartment Complex Name

Street

City

State

Zip

County

Rent or Own

Years at Address

Previous Applicant Address

Street

City

State

Zip

County

Rent or Own

Years at Address

Co-Applicant Information

Number of Co-Applicants

Co-Applicant First Name

Co-Applicant Middle Initial

Co-Applicant Last Name

SSN

Co-Applicant DOB

Co-Applicant Phone 1

Co-Applicant Phone 2

Co-Applicant Email

Marital Status

Co-Applicant Address

Apartment Complex Name

Street Address

City

State

Zip

County

Rent or Own

Years at Address

Previous Co-Applicant Address

Street

City

State

Zip

County

Rent or Own

Years at Address

Other Residents in Home

Name of Other Resident 1

SSN of Other Resident 1

DOB of Other Resident 1

Gender of Other Resident 1

Relationship to Other Resident 1

Name of Other Resident 2

SSN of Other Resident 2

DOB of Other Resident 2

Gender of Other Resident 2

Relationship to Other Resident 2

Name of Other Resident 3

SSN of Other Resident 3

DOB of Other Resident 3

Gender of Other Resident 3

Relationship to Other Resident 3

Name of Other Resident 4

SSN of Other Resident 4

DOB of Other Resident 4

Gender of Other Resident 4

Relationship to Other Resident 4

Name of Other Resident 5

SSN of Other Resident 5

DOB of Other Resident 5

Gender of Other Resident 5

Relationship to Other Resident 5

Name of Other Resident 6

SSN of Other Resident 6

DOB of Other Resident 6

Gender of Other Resident 6

Relationship to Other Resident 6

Name of Other Resident 7

SSN of Other Resident 7

DOB of Other Resident 7

Gender of Other Resident 7

Relationship to Other Resident 7

Name of Other Resident 8

SSN of Other Resident 8

DOB of Other Resident 8

Gender of Other Resident 8

Relationship to Other Resident 8

Willingness to Partner

Applicant Sweat Equity

Co-Applicant Sweat Equity

Applicant $1000 towards Insurance

Co-Applicant $1000 towards Insurance

Present Housing Conditions

Number of Bedrooms

Number of Bathrooms

Does Rent Include Utilities

Utility Statement Provided

Monthly Rent Amount

Is Rent Subsidized

Why present home is inadequate

Applicant Landlord Information

Name of Current Landlord

Landlord Phone

Landlord Street Address

Landlord City

Landlord State

Landlord Zip

Years at Address

Previous Landlord

Name of Previous Landlord

Landlord Phone

Landlord Street Address

Landlord City

Landlord State

Landlord Zip

Co-Applicant Landlord Information

Name of Current Landlord

Landlord Phone

Landlord Street Address

Landlord City

Landlord State

Landlord Zip

Years at Address

Previous Landlord

Name of Previous Landlord

Landlord Phone

Landlord Street Address

Landlord City

Landlord State

Landlord Zip

Applicant Employment Information

Applicant Employment Status

Applicant Employer Name 1

Applicant Employment Start Date 1

Applicant Employer Name 2

Applicant Employment Start Date 2

Applicant Employer Name 3

Applicant Employment Start Date 3

Co-Applicant Employment

Co-Applicant Employment Status

Co-Applicant Employer Name 1

Co-Applicant Employment Start Date 1

Co-Applicant Employer Name 2

Co-Applicant Employment Start Date 2

Co-Applicant Employer Name 3

Co-Applicant Employment Start Date 3

Household Income (Monthly)

How many residents in the home have income?

Resident Name for Monthly Income 1

Wages Resident 1

SS, SSDI, SSI Resident 1

Temporary Assistance Resident 1

VA Benefits Resident 1

Child Support/Alimony Resident 1

Payments from Trusts, Annuities, Retirement, Pensions Resident 1

Rental Income Resident 1

Monthly income from other sources Resident 1

Resident Name for Monthly Income 2

Wages Resident 2

SS, SSDI, SSI Resident 2

Temporary Assistance Resident 2

VA Benefits Resident 2

Child Support/Alimony Resident 2

Payments from Trusts, Annuities, Retirement, Pensions Resident 2

Rental Income Resident 2

Monthly income from other sources Resident 2

Resident Name for Monthly Income 3

Wages Resident 3

SS, SSDI, SSI Resident 3

Temporary Assistance Resident 3

VA Benefits Resident 3

Child Support/Alimony Resident 3

Payments from Trusts, Annuities, Retirement, Pensions Resident 3

Rental Income Resident 3

Monthly income from other sources Resident 3

Resident Name for Monthly Income 4

Wages Resident 4

SS, SSDI, SSI Resident 4

Temporary Assistance Resident 4

VA Benefits Resident 4

Child Support/Alimony Resident 4

Payments from Trusts, Annuities, Retirement, Pensions Resident 4

Rental Income Resident 4

Monthly income from other sources Resident 4

Resident Name for Monthly Income 5

Wages Resident 5

SS, SSDI, SSI Resident 5

Temporary Assistance Resident 5

VA Benefits Resident 5

Child Support/Alimony Resident 5

Payments from Trusts, Annuities, Retirement, Pensions Resident 5

Rental Income Resident 5

Monthly income from other sources Resident 5

Resident Name for Monthly Income 6

Wages Resident 6

SS, SSDI, SSI Resident 6

Temporary Assistance Resident 6

VA Benefits Resident 6

Child Support/Alimony Resident 6

Payments from Trusts, Annuities, Retirement, Pensions Resident 6

Rental Income Resident 6

Monthly income from other sources Resident 6

Financial Accounts Information

Number of financial accounts

Name on Financial Account 1

Bank Name for Account 1

Account Type for Account 1

Current Balance for Account 1

Name on Financial Account 2

Bank Name for Account 2

Account Type for Account 2

Current Balance for Account 2

Name on Financial Account 3

Bank Name for Account 3

Account Type for Account 3

Current Balance for Account 3

Name on Financial Account 4

Bank Name for Account 4

Account Type for Account 4

Current Balance for Account 4

Name on Financial Account 5

Bank Name for Account 5

Account Type for Account 5

Current Balance for Account 5

Name on Financial Account 6

Bank Name for Account 6

Account Type for Account 6

Current Balance for Account 6

Name on Financial Account 7

Bank Name for Account 7

Account Type for Account 7

Current Balance for Account 7

Name on Financial Account 8

Bank Name for Account 8

Account Type for Account 8

Current Balance for Account 8

Name on Financial Account 9

Bank Name for Account 9

Account Type for Account 9

Current Balance for Account 9

Name on Financial Account 10

Bank Name for Account 10

Account Type for Account 10

Current Balance for Account 10

Name on Financial Account 11

Bank Name for Account 11

Account Type for Account 11

Current Balance for Account 11

Name on Financial Account 12

Bank Name for Account 12

Account Type for Account 12

Current Balance for Account 12

Name on Financial Account 13

Bank Name for Account 13

Account Type for Account 13

Current Balance for Account 13

Name on Financial Account 14

Bank Name for Account 14

Account Type for Account 14

Current Balance for Account 14

Name on Financial Account 15

Bank Name for Account 15

Account Type for Account 15

Current Balance for Account 15

Name on Financial Account 16

Bank Name for Account 16

Account Type for Account 16

Current Balance for Account 16

Applicant Legal Name

Co-Applicant Legal Name

Deed

Referral Information

How did you hear about us?

How did you hear about us - Another Agency

How did you hear about us - Another Habitat Repair Program Participant

How did you hear about us - Other

Submit a new Repair Application