Home Repair Intake Form

Contact Details

Birthdate

Street Address

State

Zip

How did you hear about us

Please answer the following questions about your home and your household

Number of household members	Number of adults
Age of oldest resident	Number of children under 18
1. Do you own the home/can show proof that you are paying the mortgage for the property? Yes No	2. Are your property taxes paid and up to date? YesNo
3. Is the property in foreclosure YesNo	4. Are you in bankruptcy? YesNo
5. Do you plan to stay in the home? YesNo	6. Do you have homeowner's insurance? YesNo
7. Do you own more than one home? YesNo	8. What is your household GROSS income (income before taxes are withheld)?*
9. What are your total assets? (must be less than $173,843, not including home)	10. What work is needed on your home?

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Notice: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The Federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, Washington, DC 20580

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