Submit Repair Application

Application Status

Funding Program

Application Current Status

Incomplete Reason

Denied Reason

Application Dates

Received Date

Denied Date

Incomplete Date

In Scope Date

In Process Date

Closed Pending Date

Completed Date

Section 1

Application Address

Street

City

State

Zip

County

Applicant Information

First Name

Middle Initial

Last Name

Birthdate

Phone 1

Phone 2

Homeowner Email

Co-Applicant Information

Number of Co-Applicants

Co-Applicant First Name

Co-Applicant Middle Initial

Co-Applicant Last Name

Co-Applicant DOB

Co-Applicant Phone 1

Co-Applicant Phone 2

Co-Applicant Email

Co-Applicant 2 Name

Co-Applicant 3 Name

Co-Applicant 4 Name

Co-Applicant 5 Name

Co-Applicant 6 Name

Co-Applicant 7 Name

Co-Applicant 8 Name

Co-Applicant 9 Name

Other Owners of Property

Additional Owners

Name of Additional Owner 1

Name of Additional Owner 2

Name of Additional Owner 3

Name of Additional Owner 4

Name of Additional Owner 5

Name of Additional Owner 6

Name of Additional Owner 7

Name of Additional Owner 8

Other Residents in Home

Please list any additional residents of the property other than the applicant and co-applicant.

Other Residents in Home

Name of Other Resident 1

DOB of Other Resident 1

Relationship to Other Resident 1

Name of Other Resident 2

DOB of Other Resident 2

Relationship to Other Resident 2

Name of Other Resident 3

DOB of Other Resident 3

Relationship to Other Resident 3

Name of Other Resident 4

DOB of Other Resident 4

Relationship to Other Resident 4

Name of Other Resident 5

DOB of Other Resident 5

Relationship to Other Resident 5

Name of Other Resident 6

DOB of Other Resident 6

Relationship to Other Resident 6

Name of Other Resident 7

DOB of Other Resident 7

Relationship to Other Resident 7

Name of Other Resident 8

DOB of Other Resident 8

Relationship to Other Resident 8

Section 2

Veteran Information

Veteran OR surviving spouse?

Name of Veteran

Primary Residence of Veteran

Branch of Service

Service Start Date

Service End Date

Years Served

Highest Rank

Hon. or General Discharge

Section 3

Residency

Applicant's primary residence?

Years in Home

Year Built

Repair Information

Priority Repair per Homeowner

Secondary Repair per Homeowner

Code Violations

Code violations on home

Section 4

Mortgage Information

Mortgage on Home

Number of mortgages

Mortgage Holder 1

Payments Current for Mortgage 1?

Mortgage Payment 1

Current Balance of Mortgage 1

Mortgage Holder 2

Payments Current for Mortgage 2?

Mortgage Payment 2

Mortgage Holder 3

Current Balance of Mortgage 2

Payments Current for Mortgage 3?

Mortgage Payment 3

Current Balance of Mortgage 3

Lien Information

Number of liens

Holder of Lien 1

Holder of Lien 2

Amount of Lien 1

Holder of Lien 3

Amount of Lien 2

Other Properties Owned

Other properties owned

Amount of Lien 3

Owner Name of Other Property 1

Address of Other Property 1

Owner Name of Other Property 2

Address of Other Property 2

Owner Name of Other Property 3

Address of Other Property 3

Taxes and Insurance Information

Payment includes taxes & insurance

Is the home insured?

Are property taxes current?

Please explain if not insured or taxes delinquent

Section 5

Applicant Employment

Applicant Employment Status

Please list the applicant's current employment.

Applicant Employer Name 1

Applicant Employment Start Date 1

Applicant Employer Name 2

Applicant Employment Start Date 2

Applicant Employer Name 3

Applicant Employment Start Date 3

Co-Applicant Employment

Co-Applicant Employment Status

Please list the co-applicant's current employment.

Co-Applicant Employer Name 1

Co-Applicant Employment Start Date 1

Co-Applicant Employer Name 2

Co-Applicant Employment Start Date 2

Co-Applicant Employer Name 3

Co-Applicant Employment Start Date 3

Household Income (Monthly)

How many residents in the home have income?

Resident Name for Monthly Income 1

Wages Resident 1

SS, SSDI, SSI Resident 1

Temporary Assistance Resident 1

VA Benefits Resident 1

Child Support/Alimony Resident 1

Payments from Trusts, Annuities, Retirement, Pensions Resident 1

Rental Income Resident 1

Monthly income from other sources Resident 1

Resident Name for Monthly Income 2

Wages Resident 2

SS, SSDI, SSI Resident 2

Temporary Assistance Resident 2

VA Benefits Resident 2

Child Support/Alimony Resident 2

Payments from Trusts, Annuities, Retirement, Pensions Resident 2

Rental Income Resident 2

Monthly income from other sources Resident 2

Resident Name for Monthly Income 3

Wages Resident 3

SS, SSDI, SSI Resident 3

Temporary Assistance Resident 3

VA Benefits Resident 3

Child Support/Alimony Resident 3

Payments from Trusts, Annuities, Retirement, Pensions Resident 3

Rental Income Resident 3

Monthly income from other sources Resident 3

Resident Name for Monthly Income 4

Wages Resident 4

SS, SSDI, SSI Resident 4

Temporary Assistance Resident 4

VA Benefits Resident 4

Child Support/Alimony Resident 4

Payments from Trusts, Annuities, Retirement, Pensions Resident 4

Rental Income Resident 4

Monthly income from other sources Resident 4

Resident Name for Monthly Income 5

Wages Resident 5

SS, SSDI, SSI Resident 5

Temporary Assistance Resident 5

VA Benefits Resident 5

Child Support/Alimony Resident 5

Payments from Trusts, Annuities, Retirement, Pensions Resident 5

Rental Income Resident 5

Monthly income from other sources Resident 5

Resident Name for Monthly Income 6

Wages Resident 6

SS, SSDI, SSI Resident 6

Temporary Assistance Resident 6

VA Benefits Resident 6

Child Support/Alimony Resident 6

Payments from Trusts, Annuities, Retirement, Pensions Resident 6

Rental Income Resident 6

Monthly income from other sources Resident 6

Section 6

Financial Accounts Information

Number of financial accounts

Name on Financial Account 1

Bank Name for Account 1

Account Type for Account 1

Current Balance for Account 1

Name on Financial Account 2

Bank Name for Account 2

Account Type for Account 2

Current Balance for Account 2

Name on Financial Account 3

Bank Name for Account 3

Account Type for Account 3

Current Balance for Account 3

Name on Financial Account 4

Bank Name for Account 4

Account Type for Account 4

Current Balance for Account 4

Name on Financial Account 5

Bank Name for Account 5

Account Type for Account 5

Current Balance for Account 5

Name on Financial Account 6

Bank Name for Account 6

Account Type for Account 6

Current Balance for Account 6

Name on Financial Account 7

Bank Name for Account 7

Account Type for Account 7

Current Balance for Account 7

Name on Financial Account 8

Bank Name for Account 8

Account Type for Account 8

Current Balance for Account 8

Name on Financial Account 9

Bank Name for Account 9

Account Type for Account 9

Current Balance for Account 9

Section 7

Referral Information

How did you hear about us?

How did you hear about us - Another Agency

How did you hear about us - Another Habitat Repair Program Participant

How did you hear about us - Other

Unique email ending with @OrionHfhSoftware.com

Submit a new Repair Application