HOME REPAIR FORM

If you are interested in our program, please complete and submit the inquiry form. If you have already submitted any inquiry either online, or by mail, no further action is required of you at this time. *This form requires an email address. If you do not have access to email, please request a form by mail by calling us at (610) 278-7710 xt. 130.

Fields marked with an * are required. This form requires an email address. If you do not have access to email, please request a form by mail by calling us at (610) 278-7710 xt. 130.

You may also request a hard copy of this form by calling us at (610) 278-7710 xt. 134. If you do not have access to email, fill in “N/A”.

Please, do not fill out this form multiple times for the same recipient. Your first entry is the only one we will use in our database.

Date*

First name*

Last name*

County*

Delaware

Montgomery

Street Address*

City*

State*

Zip Code*

Current mailing address - if different than the permanent address (if it’s the same, type “same”)*

The WHRP Application can be completed in two different ways. Please review each selection below and choose the option that you prefer:*

Online

Physical

Online - Choose this option if you prefer to complete our program application digitally. HFHMD is partnering with Neighborly, an online software that will allow homeowners the option to complete their application fully online, including the ability to upload all required supporting documents.

Physical - A hard copy of the application will be mailed to you directly. The application and supporting documents must then be submitted back to Habitat via mail.

Phone Number *

Email Address*

Is your home currently insured? If “no” you are not eligible for this program*

Yes

Has Habitat MontDelco completed work on your home before?*

Yes

Optional Fields Only Select Yes If Applicable

Due to specialized funding sources, we like to offer the optional opportunity for homeowners to identify themselves or members of their household, as one or more of the following:

Currently serving in any branch of the military

Yes

Veteran with a general or honorable discharge

Yes

Disabled and in need of accessibility modifications

Yes

Over the age of 65 and interested in aging in place

Yes

Briefly describe your home’s needs:*

I affirm that I have read and understand all the information about Habitat MontDelco’s Home Repair programs(s) published on the Habitat MontDelco website. *

Yes

I both understand and affirm that Habitat MontDelco’s home repair programming may require some form of repayment plan or property lien, depending on the requirements of the funding source(s) used.

I understand if I am not comfortable with a repayment requirement associated with an application opportunity, I am welcome to decline and wait for the next opportunity. *

Yes

I understand that this online program inquiry form is not the same as a program application and that Habitat MontDelco will mail me a program application directly when funding is available and applicable to my home’s needs. *

Yes

Please, do not fill out this form multiple times for the same recipient. Your first entry is the only one we will use in our database.

First name

Last name

County *

Delaware

Montgomery

Street address of home in need of repair

Street Address

City

Region/State/Province

Postal / Zip code

Current mailing address - if different than the permanent address (if it’s the same, type “same”)*

Street Address

City

Region/State/Province

Postal / Zip code

Phone

Is your home currently insured? If “no” you are not eligible for this program *

Yes

Has Habitat MontDelco completed work on your home before? *

Yes

If Habitat MontDelco worked on your home before, when was the approximate date of work? (please mark “N/A” if Habitat MontDelco has not worked on your home before.)*

This program has a maximum annual income allowed for program participation that is based on household size. Does your household have a total gross household income below the levels listed in the chart below? *

Yes

No- if “no”, you are not eligible for this program

25' HOUSEHOLD INCOME CHART Home Repair Program.jpg

Briefly describe your home’s needs:

The WHRP Application can be completed in two different ways. Please review each selection below and choose the option that you prefer: *

ONLINE - Choose this option if you prefer to complete our program application digitally. HFHMD is partnering with Neighborly, an online software that will allow homeowners the option to complete their application fully online, including the ability to upload all required supporting documents.

PHYSICAL - A hard copy of the application will be mailed to you directly. The application and supporting documents must then be submitted back to Habitat via mail.

Optional Fields * Due to specialized funding sources, we like to offer the optional opportunity for homeowners to identify themselves or members of their household, as one or more of the following:

Currently serving in any branch of the military

Veteran with a general or honorable discharge

Disabled and in need of accessibility modifications

Over the age of 65 and interested in aging in place

Prefer Not to Say

I affirm that I have read and understand all the information about Habitat MontDelco’s Home Repair programs(s) published on the Habitat MontDelco website. *

Yes

I both understand and affirm that Habitat MontDelco’s home repair programming may require some form of repayment plan or property lien, depending on the requirements of the funding source(s) used. I further understand that if I am not comfortable with a repayment requirement associated with an application opportunity, I am welcome to decline and wait for the next opportunity. *

Yes

I understand that this online program inquiry form is not the same as a program application and that Habitat for Humanity of Montgomery and Delaware Counties will mail me a program application directly when funding is available and applicable to my home’s needs. *

Yes

HOME REPAIR FORM

Optional Fields Only Select Yes If Applicable

Thanks for submitting!