New homeowner intake

Blank answers are saved as "unknown". Unknowns never rule a program out; they turn into questions to ask when you call.

1. Client and consent

Homeowner name * Homeowner phone

Information provided by (if not the homeowner) The homeowner agreed to let me collect these details and contact programs for them *

Date of consent How consent was given

2. Property address

Street address, city, ZIP

County City ZIP

Township

3. Ownership and the home

Years in the home Title situation Home type

4. Household and income

Age of oldest owner People in household Household income, per year, all sources

Social Security, pensions, wages and any other income for everyone in the home.

5. Veteran status, health and mobility

VA disability rating (%)

6. The repair

How urgent?

Estimate, low ($) Estimate, high ($)

7. Financial position Savings

Earlier repair grants or liens on this home Notes

Programs for