Basic Contact Information: * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Do you own or rent this home: * Household Information Yes No Are there children, elderly, or disabled individuals living in the home? (Yes/No, + optional space to explain) * Yes No Please explain: What type of help are you seeking? * Roof repair or replacement Safety-related home repairs Other (please describe) * Briefly describe your situation and why you are requesting assistance * Are there any safety concerns in the home right now? * Are you currently employed? * Yes No Total monthly household income (approximate): * Do you currently receive government assistance (SNAP, SSI, Housing, etc.)? Yes No Consent * I certify that the information provided is true to the best of my knowledge. I understand that submitting this application does not guarantee services. Signature - Type Name (Digital) * Date * MM DD YYYY We’ve received your application and will carefully review the information you provided. A member of our team will reach out to you shortly regarding next steps. We appreciate your patience and the opportunity to serve you.
