Home Repair Request Form Contact Us CONTACT INFORMATIONPlease list the person that will be the main contact for the inquiry. Name* First Last Phone NumberEmail HOUSEHOLD INFORMATIONLegal Name of Homeowner #1 Date of Birth of Homeowner #1 Age of Homeowner #1 Phone Number of Homeowner #1 Email of Homeowner #1 Employer of Homeowner #1 If there is a second person listed on the mortgage, complete homeowner #2 sectionHomeowner #2 Legal Name Homeowner #2 Date of Birth Homeowner #2 Age Homeowner #2 Phone Homeowner #2 Email Homeowner #2 Employer Household InformationName(s) on the title of the home Month/ year purchased or last changed deed date Year home was built:* Year roof was last replaced or repaired? How old is your furnace?* 15 years old or older Under 15 years old My furnace uses (check all that apply): Natural Gas Propane Wood Pellets Address - Please list the address of the home that you are inquiring about repairs.* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code List the name, ages and relationship to you of ALL people living in your homeList legal name, date of birth, age and relationship to youAre you or anyone living in the home a veteran ? Yes No Are you or anyone living in the home currently serving in a branch of the military? Yes No Do you need a wheelchair ramp? Yes No Are you current on all mortgage payments? Yes No Do you have homeowners insurance and is it current? Yes No Please note, the repair program requires current homeowner insuranceAre you current on all property taxes? Yes No Please note, the repair program requires all property taxes to be current.Homeownership (check all that apply)* I am the legal owner of my home, my name is listed on the property deed I am NOT the homeowner; I am renting the home I have a land contract I am renting to own The home is my primary residence I am current on my mortgage or current on a payment plan for delinquent payments I am current on my property taxes or current on a payment plan for delinquent taxes I am currently have homeowners insurance and am current on the policy Length of years of ownership of home:* Type of Home* Single Family Duplex Condo Modular Home Please note, mobile homes do not qualify for this programAre you a Consumers Energy Customer? Yes No PROGRAM ELIGIBILITYPlease answer the questions below to provide Habitat with information about your current housing status, ability to pay for repair services and your willingness to partner with our organization.Is your home located in the Bay City Rd Corridor ? Yes No Ability to pay (check all that apply): I understand that some programs Habitat uses may charge a reasonable fee for the services I am approved for I understand my fee will be reviewed with me and agreed upon prior to project approval Willingness to Partner (check all that apply): I am willing to supply all necessary paperwork as required by the programs I am willing to complete the required number of sweat equity hours for my home repair within the organization I am willing to display partnership materials such as a lawn sign Please describe the home repair need:*Pictures of home repair needed? Please choose one of the following.* I can provide pictures of item needing repair I need someone to come and take pictures of my repair request for me? Upload Picture of Requested Repair Drop files here or Select files Max. file size: 2 GB. Have you requested assistance from another agency or church? Yes No If you answered yes to the above, which agency or church did you work with?*How did you hear about Midland County Habitat for Humanity's repair program?*
