Housing Rehabilitation Program
Pre-Application Form
(To be Competed and Submitted by Head of Household. Please Answer all Questions.)
* Indicates a required field.
* Indicates that at least one of the fields must be filled out.

Homeowner's Name
Last Name First Name Middle Name
*  *  * 
Homeowner's Address
Street City, State Zip Code
*  *  * 
Homeowner's Date of Birth
and Marital Status
Date of Birth Marital Status
Homeowner's Contact Information
Home Phone Cell Phone Email
*  *  * 
Alternate Contact Person
Last Name First Name Relationship Phone
Number of Persons Living in Home
(include related & non-related
persons using your home as their
permanent residence)
Number of Persons
Please provide your household’s total gross annual income:
(Include all money earned by each household member over 18 years of age. Household members include related and non-related persons using your home as a permanent residence. Income should include wages, AFDC, alimony, Social Security benefits, pensions, child support, regular financial support from friends or family, and interest earned on bank accounts and investments. This information will be verified by the Community Development Department if you are eligible to apply for the program.)
Total Gross Annual Household Income $  
What year was this home built? If you’re not sure of the
year it was built, do you believe the home was built
before 1978 (yes or no)?
Year home was built?  
Built before 1978?
What type of home do you own?
How many years have you owned and lived in this home?
Number of years -  
Do you have a mortgage on your home?
Mortgage on home?
If you have a mortgage, are your payments up-to-date?
Payments up-to-date?
Are the property taxes for this property up-to-date?
Prop. taxes up-to-date?
Is your home in a FEMA flood zone? If you’re not sure,
do you pay flood insurance?
Home in flood zone?
Pay flood insurance?
Do you own other homes? If yes, please provide the
Own other homes?
If "Yes", enter full address(es)