Habitat for Humanity of the Greater Harrisburg Area | Critical Home Repair Application

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Questionnaire

Homeowner Name (if different than above)

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Please choose your location

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What type of dwelling do you live in?

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Does a U.S. veteran live in the home?

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Homeowner Date of Birth

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Describe the problem you would like to have repaired:

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Total number of persons in the household

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Number of children (under age 18)

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Number of adults

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Number of working adults in the household

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Names of adult members of the household

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Income sources for adults in the household

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Is the homeowner 62 years of age or older?

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Names and ages of children in the household

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Estimated Household Annual Income (You will need to provide documentation at a later date)

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What would it mean to you and your family to have these critical home repairs completed?

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Does anyone in the household have a disability? If YES, please describe.

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Race of Head of Household: (select all that apply)

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Ethnicity of Head of Household:

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Any additional information that you would like Habitat to know regarding this application

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You are required to submit ALL of the documents listed below, via e-mail or US Mail. Please select all documents you have submitted. NOTE: Application will NOT be processed unless ALL documents are received.

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	Habitat for Humanity of the Greater Harrisburg Area Critical Home Repair Application

Thank you for your interest in Harrisburg Habitat Critical Home Repair Program. Below is a brief description of the program as well as an application.

At this time, we are not currently accepting applications for

Critical Home Repair.

Please be aware that we are not able to handle emergencies. Additionally, due to our grant funding requirements and the high demand for our services, there may be an extended wait time. In order to be put on the list as soon as possible, we will need the completed application as well as the required documents for the following:

Proof of Income (please send copies, for each household member over 18 years old):

¨ Federal Tax Return –(Current year return). Those that receive Social Security as sole income should provide current year Social Security benefit’s statement and the last three months bank statements.

¨ Income Verification–past six (6) weeks for each household member (i.e.: wages, pension, social security, disability, unemployment, child support, etc..).

Proof of Ownership (please send one (1) copy each of):

¨ Property Deed

¨ Mortgage payment invoice/receipt (most recent)

¨ Homeowner’s insurance Declaration page (most recent proof of insurance)

U.S. Veteran: (If applicable)

¨ Certificate of Veteran Status

Note: As per Federal regulations, we are required to ask ethnic/racial data of you for this application. (Information will be confidential and is used for statistical reporting only.)

To provide the required documents, you must e-mail or USPS mail the documents. No further contact from our office will take place until ALL documents are received.

Email: acardillo@harrisburghabitat.org

Mailing address: 2416 Park Drive, Harrisburg, PA 17110

All questions must be answered and requested files must be received in order to begin processing the application. If you wish to have a copy of the application mailed to you, please call the office to request. Once again, thank you for your interest in our program and please feel free to call 717-545-7299 with any questions.