Habitat for Humanity of the Greater Harrisburg Area | Critical Home Repair Application

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Home Work

Address Address

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Apartment, suite, etc. (optional) Apartment, suite, etc. (optional)

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Questionnaire

Homeowner Name (if different than above) Homeowner Name (if different than above)

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Please choose your location Please choose your location

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What type of dwelling do you live in? What type of dwelling do you live in?

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Best Time to contact Best Time to contact

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Does a U.S. veteran live in the home? Does a U.S. veteran live in the home?

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Homeowner Date of Birth Homeowner Date of Birth

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Describe the problem you would like to have repaired: Describe the problem you would like to have repaired:

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Total number of persons in the household Total number of persons in the household

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Number of children (under age 18) Number of children (under age 18)

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Number of adults Number of adults

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Number of working adults in the household Number of working adults in the household

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Names of adult members of the household Names of adult members of the household

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Income sources for adults in the household Income sources for adults in the household

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Is the homeowner 62 years of age or older? Is the homeowner 62 years of age or older?

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Names and ages of children in the household Names and ages of children in the household

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Estimated Household Annual Income (You will need to provide documentation at a later date) Estimated Household Annual Income (You will need to provide documentation at a later date)

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What would it mean to you and your family to have these critical home repairs completed? What would it mean to you and your family to have these critical home repairs completed?

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Does anyone in the household have a disability? If YES, please describe. Does anyone in the household have a disability? If YES, please describe.

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Race of Head of Household: (select all that apply) Race of Head of Household: (select all that apply)

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Ethnicity of Head of Household: Ethnicity of Head of Household:

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Any additional information that you would like Habitat to know regarding this application Any additional information that you would like Habitat to know regarding this application

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You are required to submit ALL of the documents listed below, via e-mail or US Mail. Please select all documents you have submitted. NOTE: Application will NOT be processed unless ALL documents are received. You are required to submit ALL of the documents listed below, via e-mail or US Mail. Please select all documents you have submitted. NOTE: Application will NOT be processed unless ALL documents are received.

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