Preservation and Repair Prescreen Questions

This is a pre-screening questionnaire, not a final application for the program. This form is to help determine if the Habitat for Humanity program might be right for your household. It is one step in the process of applying.

Equal Housing Opportunity: We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status or national origin.

First Name

* Required

Middle Name

Last Name

* Required

Address

* Required

Apt / Unit

City

* Required

State

* Required

Zip

* Required

Primary Phone

* Required

Alternate Phone Number

Account Information
Your email address will serve as your username when logging in going forward.

* Required

Please choose a password

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Number of Females in Household

* Required

Number of Males in Household

* Required

How many members of your household are...

Veteran?

* Required

Active Military?

* Required

Disabled?

* Required

Elderly (Over 62)?

* Required

First Responder?

* Required

What is the Total Income of all adults living in the home?

* Required

Property Ownership?

* Required

Do you have homeowner's insurance?

* Required

Are your property taxes up to date?

* Required

Is this home your primary residence?

* Required

If so, how long?

How did you hear about our program?

* Required

What work needs to be done to the exterior of the property?

* Required

Anything else we should know?

* Required

Date Submitting this Pre-screener

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Preservation and Repair Program: Prescreen Questionnaire