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Neighborhood Revitalization-Home Repair Intake Form

Personal Information
First Name
Last Name
Country
Address Line 1
Address Line 2
City
State
Postal Code
Do you own the home where work is to be done?
Is this your primary residence?
Employment
Household Information
Is anyone in the home disabled?
Is anyone in the home a veteran?
Household Budget
Mortgage Details
Do you have a reverse mortgage?
Do you pay a mortgage on your home?
Does your monthly payment include property taxes and homeowner's insurance?
Do you currently have insurance on the home?
Repair Request
Homeowner Agreement

I understand that by submitting this intake, I am authorizing Habitat for Humanity of Clallam County to evaluate my need for the home repairs. I understand that the evaluation will include a home assessment by Habitat's representatives. I give permission for photos to be taken of my home. I have answered all of the questions on this form truthfully. I understand that if I have not answered the questions truthfully, my request may be denied and that even if I have already been selected to receive a Habitat repair, I may be disqualified from the program. The original or a copy of this form will be retained by Habitat for Humanity. I hereby authorize Habitat for Humanity of Clallam County to conduct credit and/or other background checks in conjunction with this request for service.

First Name
Last Name
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Complete the following if you are not the Homeowner, but are assisting the Homeowner in completing the Intake Form:
First Name
Last Name
  • Equal Housing Opportunity
    Equal Housing Opportunity