Home Repair Application Form

Printable General Home Repair Application
All fields with an * are required.
Head of Household Contact
Property Location

My mailing address is different than the physical address
Mailing Address (if different)
Home Information
* Do you own the home?
(For informational purposes. Answer will not affect selection process.)
Yes     No



* Do you own the land?
(For informational purposes. Answer will not affect selection process.)
Yes     No




* Are there people in the home who would be able to help work?
Yes     No


* Are you able to help purchase some of the materials?
Yes     No

Note: Experience Mission is not always able to cover all materials costs. If you are not able to help with the purchase of materials this could affect your house being selected.

Explain:

* Do you have electrical service?
Yes     No

Explain:
Explain:

* Has Experience Mission ever worked on your home?
Yes     No



* Are you willing to let EM share your application with other home repair agencies?(EM will only do this if another organization may be able to help.)
Yes     No

Repairs Requested
Please prioritize the needed repairs on the home and describe the top four repairs you would like to submit in this application.
Please prioritize the needed repairs on the home and describe the top four repairs you would like to submit in this application.










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