Homeowner Intake Eligibility Questionnaire
Please fill out the questions and information below to the best of your ability. Once the form has been submitted, it may take anywhere from 6 - 12 months before the next steps in the process are initiated. Submission of this form does NOT guarantee that we will be able to provide repairs to your home, but you will be put into our system and accounted for.
What is the First and Last Name of the Homeowner? *
Your answer
What is the Homeowner(s) Date of Birth? *
MM
/
DD
/
YYYY
If there are multiple Homeowners, please list their name and date of birth (e.g. Jane Doe 07/04/1986).
Your answer
What is the Street Address of the home needing repair(s)? *
Your answer
What is the best Phone Number to contact the Homeowner(s)? *
Your answer
If the Homeowner(s) has an Alternative Contact (child, sibling, friend, etc.), please provide their name, phone number, and relationship to Homeowner(s).
Your answer
If the Homeowner(s) uses Email, please provide the address.
Your answer
Are there any people living in the home under the age of 18? If so, what are their names, ages, and relationship to Homeowner(s)?
Your answer
What is the Monthly Income of the household? *
Your answer
What is the Source(s) of the Monthly Income (Social Security, Pension, Work, Rent, Disability, etc.)? *
Required
For any other residents of the household, please provide their name, monthly income, and source(s) of their income (e.g. John Doe - $900 - Social Security).
Your answer
Does the Homeowner(s) have a Mortgage on their home? *
How did the Homeowner(s) receive their home? (Purchased by them? Passed from generations?) *
Your answer
What year was the home purchased? *
Your answer
What year was the home built?
Your answer
Does the Homeowner(s) own any other property inside or outside Louisiana? *
If so, what is the address(es) of the property?
Your answer
What material(s) is the exterior (i.e. the siding) of the home made of? *
Required
What is the size of the home?
Is the home a Single, Double, or Triplex?
Is the home 1 story, 2 story, or a Camelback?
How many bedrooms are in the home?
Your answer
How many bathrooms are in the home?
Your answer
Does the Homeowner(s) currently have Flood Insurance? *
Name of Flood Insurance Company?
Your answer
Does the Homeowner(s) currently have Homeowner's Insurance? *
Name of Homeowner's Insurance Company?
Your answer
Is the Homeowner(s) a Veteran or the widow of a Veteran? *
What types of repairs does the home need? *
Your answer
Who filled out this questionnaire? *
Your answer
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