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Preliminary Owner-Occupied Rehabilitation Application

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First Name
Last Name
Address1
Address2
City
State
Zip
Phone Number
Email address
Total Number of Household Members
Total Household Income From All Sources
Are you 62 years of age or older?
1. Yes
2. No
Are you or someone in your household a veteran?
1. Yes
2. No
Type of property (check one)
1. Detached Single Family
2. Townhouse
3. Condominium
Assistance Need (check all that apply)
1. Roof
2. Exterior Paint
3. Impact Resistant Windows or Shutter System
4. Doors (including Garage Door)
5. Fence
6. Driveway
7. Public Sidewalk
8. Public Walkways
9. Irrigation System
10. Landscaping (sod, tree trimming, tree removal or installation)
11. Security Lighting
12. Sewer Connection
13. Other