2024 Intake Eligibility Form

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2024 Intake Eligibility Form

Please fill out the following information to see if you or the homeowner you are applying for qualify for services from Rebuilding Together Atlanta. Repairs are made as funding is available. Generally homes located outside of the RTA service area (City of Atlanta, City of Smyrna) will not be considered for services, unless a veteran.

This is not an application but only prequalifies you for repairs.

Intake Eligibility Form

HOMEOWNER INFORMATION

Homeowner First Name *

Homeowner Last Name *

Homeowner or contact email

The best phone number(s) to reach you or the homeowner *

Street Address *

City, State and Zip *

Is homeowner 62 years old or older? *

Homeowner DOB *

YYYY

Does the homeowner own and occupy the home? *

Yes

Do you have active and current homeowner's insurance in your name? *PLEASE NOTE- If you qualify for assistance, RTA will need a copy of the declaration page of your policy. *

Yes

I don't know

Gender *

Male

Female

Non Binary

Other

Does the homeowner have a disability? *

Yes

Is the homeowner a veteran? *

Yes

Is anyone in your household currently serving in the military? *

Yes

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