Home Repair Inquiry | livingstonhabitat

Critical Home Repair Inquiry Form

Full Name

Phone

Address, City, State, Zip Code

Are you a veteran?

Over 60 years old?

Number of adults in the home

Number of minors in the home

Do you own the home? (This is a requirement)

Is residence a mobile home?

Is the home currently covered by insurance?

Total monthly income of owner(s)

Description of repairs needed

Referred by (if any)

I consent to the use of photographs and/or videos for publicity. I understand I may revoke this consent at any time in writing, though this action will not affect any use of the above materials prior to revoking consent.

Type in full name as consent of signature and understanding that your project will be assessed by us and if you qualify, additional information will be required. Project will be completed once funding is available.

I understand this is not an emergency repairs program. If immediate assistance is necessary I will have to contact an emergency repairs program. Yes or no.