CDBG Critical Home Repair Program Application

Your Contact Information

First Name *

Last Name *

Email *

Address Line 1 *

Address Line 2

Phone

City *

State *

Zip *

It is the policy of Habitat for Humanity to offer the services of this program regardless of race, color, religion, national origin, sex, elderliness, familial status, source of funds, sexual orientation, gender identity, status as a veteran, or disability.

Please complete this pre-screening application to determine if you qualify for the Habitat for Humanity Critical Home Repair program. Please fill out the application as completely and accurately as possible. All information you include will be kept confidential.

Applicant Information

Physical Address of Residence * The field Physical Address of Residence is required.

Mailing Address (if different) The maximum length for the field Mailing Address (if different) is 500 characters.

Applicant Info

Applicant First Name * The field Applicant First Name is required.

Applicant Last Name * The field Applicant Last Name is required.

Applicant Phone Number * The phone field Applicant Phone Number is required.

Applicant Email Address * The email field Applicant Email Address is required.

Applicant Date of Birth * The date field Applicant Date of Birth is required.

Preferred Contact Method * The field Preferred Contact Method is required.

Preferred Language * The field Preferred Language is required.

Veteran/Military Affiliation * The field Veteran/Military Affiliation is required.

If yes, which branch? The maximum length for the field If yes, which branch? is 500 characters.

Co-Applicant First Name * The field Co-Applicant First Name is required.

Co-Applicant Last Name * The field Co-Applicant Last Name is required.

Co-Applicant Phone Number * The phone field Co-Applicant Phone Number is required.

Co-Applicant Email Address * The email field Co-Applicant Email Address is required.

Co-Applicant Date of Birth * The date field Co-Applicant Date of Birth is required.

Co-Applicant Preferred Contact Method * The field Co-Applicant Preferred Contact Method is required.

Co-Applicant Preferred Language * The field Co-Applicant Preferred Language is required.

Co-Applicant Veteran/Military Affiliation * The field Co-Applicant Veteran/Military Affiliation is required.

If yes, which branch? The maximum length for the field If yes, which branch? is 500 characters.

Household Members

Who lives in the household other than applicant or co-applicant?

First Name The maximum length for the field First Name is 500 characters.

Last Name The maximum length for the field Last Name is 500 characters.

Relationship to Applicant/ Co-Applicant The maximum length for the field Relationship to Applicant/ Co-Applicant is 500 characters.

Demographics and Agency Info

Receiving Assistance from any of the following?

Ethnicity

Applicant Ethnicity * The field Applicant Ethnicity is required.

Co-Applicant Ethnicity * The field Co-Applicant Ethnicity is required.

Gender

Applicant Gender * The field Applicant Gender is required.

Co-Applicant Gender * The field Co-Applicant Gender is required.

Race

Applicant Race

Co-Applicant Race

Present Housing Conditions

Describe repairs/modifications needed * The field Describe repairs/modifications needed is required.

Property Information

Is Your Home A Mobile Home? * The field Is Your Home A Mobile Home? is required.

Do You Rent Or Own? * The field Do You Rent Or Own? is required.

Resident of Harrisonburg? * The field Resident of Harrisonburg? is required.

Is Your Home Your Primary Dwelling? * The field Is Your Home Your Primary Dwelling? is required.

Financial Information

Amount of Monthly Mortgage/Rent Payment * The field Amount of Monthly Mortgage/Rent Payment is required.

Unpaid Balance (if mortgage) The maximum length for the field Unpaid Balance (if mortgage) is 500 characters.

Are your mortgage/rent payments up to date? * The field Are your mortgage/rent payments up to date? is required.

If not, how many payments behind? The maximum length for the field If not, how many payments behind? is 500 characters.

Property Taxes Paid or in Escrow (if applicable)

Is Homeowners Insurance current (if applicable)

How many persons in household? * The field How many persons in household? is required.

Are All in Household Related? * The field Are All in Household Related? is required.

If no, please explain The maximum length for the field If no, please explain is 500 characters.

Total Gross Annual Household Income * The field Total Gross Annual Household Income is required.

Source(s) of Income/Employer * The field Source(s) of Income/Employer is required.

Work Phone * The phone field Work Phone is required.

Authorization and Release

I understand that by filing this application, I am authorizing Central Valley Habitat and Habitat Partners to contact other organizations to evaluate my actual need for the home repair program. I understand that the evaluation will include personal visits, a credit check, and income verification. I have answered all the questions on this application truthfully. I understand that if I have not answered the questions truthfully, my application may be denied, and that even if I have already been selected to receive home repairs, I may be disqualified from the program. The original or a copy of this application will be retained by Habitat for Humanity even if the application is not approved.

Families will be expected to take a Homeowners Budget Class which will help you maintain ownership. This will also help you to be able to avoid scams and foreclosure.

A 5-year payment plan may be established in order to aid in the homeowner payment portion.

I also understand that all applicants are screened on the sex offender registry. By completing this application, I am submitting myself to such an inquiry. I further understand that by completing this application, I am submitting myself to a criminal background check.

By checking the box below, you are agreeing to participate in a network made up of health and social service partners (“The Network”) who work together to connect clients with services to connect you to people/agencies that can help you, we ask you to allow us to share your information with those partners. Your information will be kept confidential and will be used to help you get the services you want. Some partners may ask you to sign another consent or authorization to share your information to comply with federal, state, and local privacy and data protection laws, such as federal HIPAA laws

Consent to share info with other agencies * The field Consent to share info with other agencies is required.

Applicant Signature * The field Applicant Signature is required.

Co-Applicant Signature * The field Co-Applicant Signature is required.

Date * The date field Date is required.

Income Eligibility

Adjusted Income Limits for Harrisonburg / Rockingham (Updated May 2024)

1 Person – $49,900
2 Persons – $57,000
3 Persons – $64,150
4 Persons – $71,250
5 Persons – $76,950
6 Persons – $82,650
7 Persons – $88,350
8+ Persons – $94,050

Does your income fall under the above? * The field Does your income fall under the above? is required.

Final Declaration

I certify that information given is true and accurate to the best of my knowledge. It is understood that the information will be used to monitor benefits provided by a HUD/CDBG Grant through the City of Harrisonburg.

Signature of Applicant * The field Signature of Applicant is required.

Signature Date * The date field Signature Date is required.