Homeowner Intake Form
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.
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What is the First and Last Name of the Homeowner? *
What is the Homeowner(s) Date of Birth? *
If there are multiple Homeowners, please list their name and date of birth (e.g. Jane Doe 07/04/1986).
What is the Street Address of the home needing repair(s)? *
What is the best Phone Number to contact the Homeowner(s)? *
Does the Homeowner(s)? have an email address? *
If the Homeowner(s) has an Alternative Contact (child, sibling, friend, etc.), please provide their name, phone number, and relationship to Homeowner(s). *
Does the Homeowner(s) have a Mortgage on their home? *
If the Homeowner does have a mortgage, how much does the Homeowner pay each month? *
Is the Homeowner(s) a Veteran or the widow of a Veteran? *
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)?
What is the Monthly Income of the household?
What is the Source(s) of the Monthly Income (Social Security, Pension, Work, Rent, Disability, etc.)? *
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). *
What is the size of the home?
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Is the home a Single, Double, or Triplex?
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Is the home 1 story, 2 story, or a Camelback?
How many bedrooms are in the home?
How many bathrooms are in the home?
What material(s) is the exterior (i.e. the siding) of the home made of?
What year was the home purchased?
Does the Homeowner(s) own any other property inside or outside Louisiana? *
Does the Homeowner(s) currently have Flood Insurance? *
Does the Homeowner(s) currently have Homeowner's Insurance? *
What types of repairs does the home need? *
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