Application for Home Repair Assistance

Complete the application below to see if you qualify

Please note: Home repair services are available for OWNER OCCUPIED homes only.

Applicant Name

First Last

Applicant Phone

Date of Application

Applicant Email

Enter Email Confirm Email

Household Address

Street Address Address Line 2 City State ZIP Code

County

Within the City Limits

Yes

Household* Occupant Information

Household - includes anyone residing at address and/or on the deed. If there is anyone on the deed that does not reside in household requesting assistance - the household is not eligible FOR FUNDING.

Head of Household Name

First Last

Head Of Household Gender

Male

Female

Head of Household Age

Please enter a number from 18 to 120.

Head of Household Birth Date

Head of Household Ethnicity/Race

*Filling this area out is optional* This information is collected to assure compliance with Fair Housing & Equal Opportunity Rules

Head of Household Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Head of Household Race

Spouse Name

First Last

Spouse Gender

Male

Female

Spouse Age

Please enter a number from 18 to 120.

Spouse Birth Date

Other Household Occupants

(Use the + button on the right-hand side to add additional occupants)

Name

Relationship

Birthdate

Are there any Veterans in the Household:

Yes

Please Specify Name(s) of Veterans

Income Verification for All Persons living in the Household

Please select any/all income sources from below:

Income Backup Files

Upload the files of all Benefit Statement letters, proof of disability statement if you are receiving Social Security Disability Benefits, or most recent payroll check stubs with year-to-date totals, and copies of proof of income from any other source selected above. ALL SOCIAL SECURITY LETTERS MUST BE DATED IN THE YEAR THE APPLICATION IS SUBMITTED.

Drop files here or

Max. file size: 25 MB.

Mortgage/Deed and Property Tax

Name of Mortgage Company/Deed Owner

Monthly Mortgage Payment

Leave at $0 if none

Past Due Poperty Taxes

Leave at $0 if none

Deed/Title/Will File(s)

Upload the files of the DEED or TITLE, or if your home was willed to you, a copy of the WILL. If you do not have a DEED or TITLE you may call the COUNTY CLERKS OFFICE at 660-9400 in Segwick Co. or your local County Court house and request a copy. (We CANNOT accept TAX RECEIPTS or APPRAISALS as home ownership proof.)

Drop files here or

Max. file size: 25 MB.

Household Size

Appraisal or County Property File(s)

If the Household is 3 or more bedrooms, an Appraisal or County Property Detail needs to be uploaded.

Drop files here or

Max. file size: 25 MB.

Repair Work Needed

List Repair Work Needed (Please be specific):

Repair Pictures/Files

Please upload photos (if able) to show repair needs of home.

Drop files here or

Max. file size: 25 MB.

Referrals and Signatures

If an individual or another agency referred you to Mennonite Housing, please list them below

Primary Applicant Sign Here:(Required)

In signing this application, I/We certify that all information provided to Mennonite Housing in this application for home repair assistance is accurate and complete. Furthermore, I/We understand that knowingly and willingly making false or fraudulent statements herein are a felony punishable by fine and imprisonment (Title 18, Section 1001, and U.S. Code).

Spouse Signature

Housing Preservation for Low-Income Families

Complete the application below to see if you qualify

Household* Occupant Information

Head of Household Ethnicity/Race

Income Verification for All Persons living in the Household

Mortgage/Deed and Property Tax

Household Size

Repair Work Needed

Referrals and Signatures

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