HOME REPAIR PROGRAM APPLICATION
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Email *
Applicant Information
First Name *
Middle Initial
Last Name *
Date of Birth: *
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Social Security Number: *
Address (Street, City, State, and Zip Code) *
Primary Phone Number *
Secondary Phone Number
Are you a United States citizen? *
Are you a Resident Alien? *
Co-Applicant Information 
First Name
Middle Initial
Last Name
Email:
Date of Birth:
MM
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DD
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YYYY
Social Security Number:
Address (Street, City, State, and Zip Code)
Primary Phone Number
Secondary Phone Number
Are you a United States citizen?
Clear selection
Are you a Resident Alien?
Clear selection
Household Income Information

List all persons who reside in the property. Income must be listed for all household members over the age of 18.

For each household member, please list their name, date of birth, relationship to the applicant and gross annual income.**

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** Sources of income include salary, overtime, bonus, commission, social security and retirement benefits, unemployment benefits, interest/dividend income, welfare, alimony and child support and all other income.

Total number of people in the household:

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Has the applicant received financial assistance from the City of Boston Mayor’s Office of Housing (formerly the Department of Neighborhood Development) in the past?
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If yes, what date did the applicant receive the financial assistance?
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If yes, what was the purpose of the financial assistance?
If yes, what is the address of the property where the applicant received the financial assistance?
Asset Information
Value of all other real estate owned (non-primary residence):
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Total funds in checking and savings accounts:
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Have you sold any assets in the last two (2) years below fair market value?
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Property Information
Please select the type of property:
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Please describe the interior and exterior repairs that are needed:
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If applicable, list the rental unit number, vacancy status, number of bedrooms, tenant name, and monthly rent for each rental unit in the property.

If not applicable, please write N/A.
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Does the property need de-leading work?
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If yes, does or will a child under 6 years of age reside in the property?
Clear selection
If no, does a child under 6 years of age visit the property on a regular basis?
Clear selection
If yes, how many hours per week does/will the child spend at the property?
Affirmative Marketing Information
Please complete the following section to assist us in fulfilling our affirmative marketing requirements. Your response is voluntary and will not affect your application.
Race of everyone in your household (check all that apply):
Does the Applicant identify as Hispanic or Latino?
Clear selection
Is the Applicant disabled?
Clear selection
Is the Applicant over 62 years of age?
Clear selection
Is the Applicant a Female Head of Household?
Clear selection
Sign and Date
I declare under the penalty of perjury that the foregoing information is true, accurate, complete and correct in all respects. I hereby authorize the City of Boston to independently verify the information provided here. I certify that I have read the Program Disclosure and I agree to the Terms and Conditions of this program. I understand that under the False Claims Act, 31 U.S.C. §§3279-3733, those who knowingly submit, or cause another person or entity to submit, false claims for payment of government funds, are liable for three times the government’s damages plus civil penalties per each false claim.
Applicant Name:
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Today's Date *
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Electronic Signature *
Required
Co-Applicant Name:
Today's Date
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Electronic Signature
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