|Homeowner Name: *|
Marital Status: *
Property Address: *
City, State, Zip: *
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?
List each member of your household INCLUDING YOURSELF and children.
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?
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)