Repair Program Interest Form
By completing the form below, you are submitting a pre-application for critical home repair through Habitat for Humanity. Please be sure to fill out all required fields. Once you submit your pre-application, our team will review your information, then follow up with you to determine the next step in the application process.
First Name
Last Name
Address
City
State
Zip Code
Phone Number
Is someone in your household over 60 years of age?
Yes
No
Did you serve, or are you currently serving, in the military?
Yes
No
If the veteran is not the homeowner, is this their primary residence?
Yes
No
Is any member of the household a surviving spouse of a veteran? (Married at the time of the veteran's death and has not remarried?)
Yes
No
Did the veteran earn an honorable or general discharge?
Yes
No
I understand that this is a request for an application and I will be mailed the application to be considered for the Repair Program
Yes
No
Submit
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