HHHV Veteran Repair Interest Form
Funding for Habitat Veteran Critical Repair program funding is assigned on an annual basis each spring. Completion of this form does not guarantee acceptance into our program. All requests received during the designated period will be assessed for program eligibility and need, based on expected scope of work. Those who are not served by Habitat will be placed on our Possible Futures list, which is used regularly to inform funding requests and to each individuals who are in need if and when funding is secured.

PLEASE FILL OUT THIS FORM AS COMPLETELY AS YOU ARE ABLE.

CONTACT INFORMATION
Name *
Your answer
Street Address *
Your answer
City *
Your answer
Zip Code *
Your answer
Phone Number *
Your answer
Email Address
Your answer
HOUSEHOLD INFORMATION
Have you ever received assistance from Habitat for Humanity of Huron Valley *
If YES, please list all programs that you have been involved in.
Your answer
Please verify the following (check if true): *
Required
How many individuals live in your home? *
Your answer
What is your estimated gross household income (please include income for all adults)? *
Your answer
Have you, or has a spouse, served in the United States Armed Forces? *
Branch of Service *
Your answer
Dates of Service (e.g., 1963-1965) *
Your answer
Discharge *
HOME REPAIR INFORMATION
To the best of your knowledge, what repairs does your home need currently? *
Your answer
Have you received any estimates from contractors for the repairs mentioned above?
Your answer
Please check any of the following types of repair needs that apply to your home currently: *
Required
THANK YOU!
Click "submit" to share your information with Habitat staff. Please note: you will not receive a response unless you are invited to formally apply for the Veteran Critical Repair program.

For more immediate assistance, please call the Washtenaw County Department of Veterans Affairs at (734) 973-4540.

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