Critical Home Repair Application : Programs : Putnam County Habitat for Humanity

This is a pre-screening questionnaire, not a final application for Critical Home Repair. This form is to help determine if the Habitat for Humanity Critical Home Repair program will be able to assist you.

Name

First Name *

Middle

Last Name *

Describe the repair(s) you need assistance with.

My home is in Putnam County

I live in the home year-round.

This is the only home that I own.

My home is under a land contract agreement.

I have owned my home for at least 2 years.

I am current on my property taxes and homeowner insurance.

Habitat for Humanity requires each participant in the Critical Home Repair Program to complete a defined number of sweat equity/volunteer hours. To your ability, are you willing to make this commitment?

Please list your total monthly household income. You will be asked to verify this information.

Please list other monthly expenses such as credit cards, car payments, insurance, child care, other loans, and any other debt.

Expense/Monthly Amount$

Do you have any outstanding collections or judgements (including past-due child support)?

Before being invited to complete a homeowner application, applicants must provide proof of citizenship or residency status and agree to a credit check, a sex offender check, and a criminal background check.

By my signature, I affirm that the information on this form is true and correct. I understand that providing false information could cause me to be disqualified. I also understand that someone from Habitat for Humanity will contact me with the results from this questionnaire, and that I MAY be invited to complete a formal application.