Preliminary Owner-Occupied Rehabilitation Application

2. First Name

3. Last Name

5. Address1

7. Address2

9. City

10. State

11. Zip

13. Phone Number

14. Email address

15. Total Number of Household Members

16. Total Household Income From All Sources

18. Are you 62 years of age or older?

    1. Yes
    2. No

19. Are you or someone in your household a veteran?

    1. Yes
    2. No

20. Type of property (check one)

    1. Detached Single Family
    2. Townhouse
    3. Condominium

22. 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

Leave This Blank:


24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field