Housing Repair Program Application & Eligibility Form

Applicant Information

First Name

Last Name

Address

Country/Region

Address

City

Zip / Postal code

Phone

Email

Do you own the home?

Yes

No

If no, explain your housing situation

Only answer if you do not own the home

Number of people living in the home

Seniors (65+)

Children under 18

Veterans in household

Yes

No

Annual household income

Enter your total annual household income in dollars

To qualify, applicants must meet one or more of the following criteria:

Please check all that apply

Please check all that apply:

Describe the issue(s)

Provide a detailed description of the issues that need to be addressed

I certify that the information provided is accurate. I authorize Fertile Ground to:

I certify that the information provided is accurate and I authorize Fertile Ground to conduct assessments and coordinate services as described above

Digital signature

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