Homeowner Name: *

Telephone: *

Cell/Work Telephone:

Email Address:

Marital Status: *

Property Address: *

City, State, Zip: *

Mailing Address:

City, State, Zip:

Has our agency helped before?
If so, when were you last assisted?

How did you hear about us?

Total Number of Household members?

Household Members:
List each member of your household INCLUDING YOURSELF and children.
1Name:(First and Last)


Veteran Status:
Date of Birth:*

Social Security#:*
(Please indicate if full time
student or disabled)

Income: (Gross Monthly)

How long have you owned this house?


Are you a U.S. Citizen or Resident

Are your property taxes current?

Is the Homestead Exemption filed on the property?

Is your mortgage current?

Do you have a reverse mortgage?

Do you owe any special assessments?

Do you have homeowner's insurance?

Do you have flood insurance?

Type of home:
If a mobile home, do you own the land?

Do you currently have pests/insects in your home?
If so, what kind?

Repairs Needed:
Roof: (Please include Age)

HVAC: (Please include age. Must submit 1 estimate explaining problem)

Septic: (Must submit Recent Pump out and Tank Certification)

Mold: (Area affected cannot exceed 2-3 sheets of paper)