SAFE HOME INITIATIVE: Resident Application
Email address *
Full name of applicant *
Address *
Contact phone number *
Do you rent or own your home? *
If you rent, what is the name and contact information of the landlord (name, phone, and email address)? *
How many people reside in your home? *
What are the ages of those residing in the home? *
What is the ratio between your average monthly gas and electricity bill and your income? *
Does your household receive government assistance of any kind? *
What is your top concerns with your home? *
Does anyone residing in the home have underlying health conditions? (Asthma, COPD, Bronchitis, Cystic Fibrosis, Auto-immunity, Chronic Inflammatory Response Syndrome, Cancer, or other condition)
How long has it been since the last improvement was made on your home and what was that improvement?
Now it's time to tell us your story. Why are you applying to the Safe Home Initiative? Here are some questions to help you get started: 1) What it is like to live in your home in its current condition? 2) Describe your primary concerns in more detail. 3) Explain how the condition of the home impacts those who live there. *
What are you hoping to achieve if your home is selected for home improvement upgrades? *
Now, we'd like to know a little bit more about your home.
What type of home do you live in?
Clear selection
How many bedrooms does your home have? *
How many bathrooms does your home have? *
Foundation type: *
Age of the home:
Number of HVAC units located outside the home:
Clear selection
Thank you for completing the application!
Applications are reviewed on the 15th of each month. Funding is awarded after an assessment of the home and is based on need as well as available funds. For additional questions, please contact us at 615-477-2822.
A copy of your responses will be emailed to the address you provided.
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