-Home Repair and Preservation Inquiry Form-

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This five (5) minute form is kept confidential and used to meet the preliminary program and project criteria.

Projects selected do not discriminate based on race, color, religion, sex, handicap, familial status, sexual orientation, age, gender identity or national origin or because all or part of the applicant income is derived from public assistance programs.

First & Last Name /Nombre y apellido *

Physical Address of Property/Dirección de propiedad *

Phone/ Teléfono *

Is this a mobile phone or land line?/ ¿Es este un teléfono móvil o una línea fija?
*

Mobile phone/Teléfono móvil

Land line/Teléfono fijo

I do not have a phone/No tengo teléfono

Other:

Email address/ Dirección de correo electrónico

Preferred communication methods *

Check all that apply.

Email/Dirección de correo electrónico

Mobile text messaage/Mensaje de texto movil

Phone/Teléfono

USPS mail/Correo usps

Required

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