Submit Repair Application

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

Please list any additional residents of the property other than the applicant and co-applicant.

Other Residents in Home

Name of Other Resident 1

DOB of Other Resident 1

Relationship to Other Resident 1

Name of Other Resident 2

DOB of Other Resident 2

Relationship to Other Resident 2

Name of Other Resident 3

DOB of Other Resident 3

Relationship to Other Resident 3

Name of Other Resident 4

DOB of Other Resident 4

Relationship to Other Resident 4

Name of Other Resident 5

DOB of Other Resident 5

Relationship to Other Resident 5

Name of Other Resident 6

DOB of Other Resident 6

Relationship to Other Resident 6

Name of Other Resident 7

DOB of Other Resident 7

Relationship to Other Resident 7

Name of Other Resident 8

DOB of Other Resident 8

Relationship to Other Resident 8

Veteran OR surviving spouse?

Veteran Information

Name of Veteran

Primary Residence of Veteran

Branch of Service

Service Start Date

Service End Date

Years Served

Highest Rank

Hon. or General Discharge

Applicant's primary residence?

Residency

Years in Home

Year Built

Priority Repair per Homeowner

Repair Information

Secondary Repair per Homeowner

Code violations on home

Code Violations

Mortgage on Home

Mortgage Information

Number of mortgages

Mortgage Holder 1

Mortgage Payment 1

Current Balance of Mortgage 1

Payments Current for Mortgage 1?

Mortgage Holder 2

Mortgage Payment 2

Current Balance of Mortgage 2

Payments Current for Mortgage 2?

Mortgage Holder 3

Mortgage Payment 3

Current Balance of Mortgage 3

Payments Current for Mortgage 3?

Number of liens

Lien Information

Holder of Lien 1

Amount of Lien 1

Holder of Lien 2

Amount of Lien 2

Holder of Lien 3

Amount of Lien 3

Other Properties Owned

Other properties owned

Owner Name of Other Property 1

Address of Other Property 1

Owner Name of Other Property 2

Address of Other Property 2

Owner Name of Other Property 3

Address of Other Property 3

Owner Name of Other Property 4

Address of Other Property 4

Owner Name of Other Property 5

Address of Other Property 5

Owner Name of Other Property 6

Address of Other Property 6

Owner Name of Other Property 7

Address of Other Property 7

Owner Name of Other Property 8

Address of Other Property 8

Owner Name of Other Property 9

Address of Other Property 9

Owner Name of Other Property 10

Address of Other Property 10

Taxes and Insurance Information

Payment includes taxes & insurance

Is the home insured?

Are property taxes current?

Please explain if not insured or taxes delinquent

Applicant Employment

Applicant Employment Status

Please list the applicant's current employment.

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 Status

Co-Applicant Employment

Please list the co-applicant's current employment.

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

How many residents in the home have income?

Household Income (Monthly)

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

Number of financial accounts

Financial Accounts Information

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

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

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