Applicant information

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A.

Aging In Place - Basic Home Repair Program

Aging in Place is a Housatonic Habitat for Humanity program for Seniors, Veterans and people who are ability challenged and on a fixed income. Excluding home equity, asset levels cannot exceed $72,000 for the total household income. Please note: Renters are not eligibe to participate in this program.

Applicant's first and last name:

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Street address:

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City/Town:

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Zip code:

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Phone number:

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Email address:

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Number of people in your household:

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Approximate household income (total income of all persons living in the home):

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Did you or your spouse/partner serve in the military:

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How did you hear about this program?

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B.

For Basic Safety:

Home Repairs or ADA Modifications Needed: please check all that apply.

Smoke/Carbon Monoxide Detectors:

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Slip resistant bath.shower mats:

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Night lighting at stairs/bedroom to bathroom:

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Non-slip pads/tape for rugs:

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C.

For Safety Enhancement:

Home Repairs or ADA Modifications Needed: please check all that apply.

Exterior walkway:

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Exterior pathway lighting:

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Stair handrails:

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Non-slip stair treads:

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Stair risers/treads:

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Zero-step/treads:

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Bathroom grab/assis bars:

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GCI outlets in kitchen/bathroom:

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Extension cord placement:

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Swap LED for lower wattage light bulbs:

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Water heater temp adjustment:

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Exterior entry ramp - referral to installation company:

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D.

For Accessibility:

Home Repairs or ADA Modifications Needed: please check all that apply.

Doorway width:

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Cabinet pulls:

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Lever door handles:

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Lever faucet handles:

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Toilet height:

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Decora light switches:

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E.

For Weatherization

Home Repairs or ADA Modifications Needed: please check all that apply.

Weather-strip exterior doors:

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First floor window insulation:

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F.

Homeowner Media Release & Partnership Acknowledgement

If you do not consent to the use of your image or testimonial for any of the purposes listed in the attached agreement plese notify a staff member to ensure accomodations are made.

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