Today's Date:

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Applicant First and Last Name:

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Street Address:

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City, State, Zip Code

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Phone:

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Email:

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Gender:

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Ethnicity:

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Date of Birth:

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Did/Does you or your spouse/partner serve in the military?

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How did you hear about Aging in Place?

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For Basic Safety (Please check all that apply):

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For Safety Enhancement (Please check all that apply):

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For Accessibility (Please check all that apply):

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For Weatherization (Please check all that apply):

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How many people living in your household:

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Approximate yearly household income (Your total income for ALL persons living in the home):

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I can provide all the required documentation listed on our website as proof of eligibility:

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I understand that by submitting this application, I am authorizing Housatonic Habitat for Humanity to evaluate my need for Aging in Place home repair or ADA modifications. I understand that this evaluation will include personal visits and income verification. I have answered all questions truthfully. I understand that by completing this application , I am submitting myself and all persons listed in household to a background check by Housatonic Habitat for Humanity.

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Enter your name below to represent your official signature of this application.

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Todays Date:

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