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Home Rehab & Repair Intake and Screening
Step
1
of
2
50%
Name
First
Last
Phone Number
(Required)
Phone Type
cell
home
work
Email
Property Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing Address
Mailing address is the same as the property address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
If different from property address
Eligibility Assessment
Do you have Health Insurance?
Yes
No
Oregon Health Plan?
Yes
No
OHP #
Insurance Company
Energy Assistance Recipient
Yes
No
Have you received Energy Assistance within the past 12 months?
Are you able to assist with repairs to your home by yourself or with volunteers?
Yes
No
Do you own your home?
Yes
No
Ownership Status
Mortgage
DMV Title
Land Sales Contract
Paid in Full
Other
Type of Building
Wood framed single family home
Manufactured home in park
Manufactured home on lot
Other
Multi-family Building
Apartment or duplex
2-4 unit building
5+ unit building
Manufactured Home Type
Single Wide
Double Wide
Other
Do you have homeowners insurance?
Yes
No
Do you have flood insurance?
Yes
No
Year Built
How many years have you lived here?
Are you property taxes current?
Yes
No
How many years owed?
Joint ownership
Yes
No
Is anyone other than you or your spouse or partner on title to your property?
Do you have any judgments or liens (other than mortgage)?
Yes
No
If yes, IRS Lien?
Yes
No
Δ
Home
Agency Forms
Home Rehab & Repair Intake and Screening
Agency Forms
Client Portal
Connector
Healthy Families Registration/Referral Form
Home Rehab & Repair Intake and Screening
Request Received
SSVF Application
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