HOME REPAIR Program Pre-Screening Form

HOME REPAIR Program Pre-Screening Form

County of Greene
Applicant Name*

First NameLast Name
Date of Birth*
Co-Applicant Name

First NameLast Name
Co-Applicant Date of Birth
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from physical address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Please answer each question to complete the HOME Investment Partnerships Program (HOME) Rehabilitating Existing Properties and Accessibility Improvements for Residents (REPAIR) screening. Once the pre-screen has been completed, amember of out prgram staff will contact you regarding eligibility and further instructions.
1. Do you own the home in which you reside?*

YesNo
If yes, please upload the Deed to your home

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Deed Cancelof
If you answered no to Question 1, please explain below:
Example: If you rent to own, have a land installment agreement, or any other agreement with the owner of the property in which you will eventually become the owner of the property
NOTE: The Greene County HOME Repair Program will consider rent-to-own properties assuming the agreement with the existing owner will be paid in full no later than five years after the proposed rehabilitation project and if they have been living in the home for at least three three years.
2. Is the home located in Greene County?*

YesNo
3. Is this property a mobile home? Mobile homes may be eligible for this program if they are on a permanent foundation. If not on a permanent foundation, the hitch and wheels must be removed and the mobile home must be connected to public utilities. The applicant must also own the land the home sits on OR have a written land lease (length of lease required is dependent upon the amount of rehabilitation grant offered).*

Yes, on a permanent foundationYes, not on a permanent foundationNo
If yes, please upload the Mobile Home Title

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Title to Mobile Home Cancelof
4. Is there a mortgage on the property?

YesNo
If yes, what is the amount owed?
5. How many people reside in the home (including minor children)? If there is a shared custody arrangement, please only county children who live in the home at least 51% of the year*
6. Is anyone in the home over the age of 62?*

YesNoNo, but someone will turn 62 in the next 6 months
7. Is anyone Disabled?

YesNo
8. Is anyone a Veteran?

YesNo
9. Head of Household:

DisabledFemaleOver the age of 62
10. Are there any children under the age of 18 that live in the home at least 51% of the year?

Yes 0-5 years oldYes 5- 17 years oldNo
11. Race and Ethnicity (select all that apply)

White CaucasianBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Pacific IslanderHispanicNot Hispanic
12.Have you received any funding from another Program in the last 5 years?

NoYes
If Yes, Please give the name of the Program and the dates you received the funding
13. Though the Home Repair Program does not have a priority list, home rehabilitation projects that the program determines to be of an emergent nature may be moved up on the waitlist at the County’s sole discretion if funding is available and if the project entails all code violations being met. Such instances constituting an emergency and thus warranting advancement on the waitlist may include, but shall not be limited to: * CYS Intervention (children need to be removed from the home due to unsafe structural components for which CYS funds cannot facilitate a timely repair for the children to remain in the home), * Severe Code Enforcement or Health Department citations that will result in condemnation of the home, or other severe structural conditions which pose an imminent life safety threat. * Are there any Health and/or Safety Hazards in your home?

YesNo
If yes, please explain.
Please upload Citations, Notices, Actions Plans, etc. to prove your emergency

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Citations, Notices, CYS Documentation, Repairs from Contractor, etc. Cancelof
If a Contractor is listing your health and/or safety hazards, we will need a copy of his Pennsylvania's Contractors License.

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Contractor's Pa Liscense. Cancelof

14. Please list any Assets (property, equipment, vehicles, savings/checking accounts totals, livestock, etc.) Do not include the home you live in or your daily vehicle.

	Household Member	Asset Descriptiond	Current Cash Value	Actual Income from Assets
Head of Household
Family Members
...
...
...
....
...
....

15. Please list the monthly gross (pre-tax) income of all household members

	Wages/Salaries	Benefits/Pensions	Public Assistance	Other Income
Head of Household
Family Members
...
...
...
...

16. What is your approximate gross (pre-tax) monthly income from all sources? If there are more sources of income then please describe them in "Other".*
Total gross monthly income
(Please use the space below to describe monthly income if needed)
Please Upload Proof of Income for each family member

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Social Security Statement, W2s, 1099s, Pension, Retirement, Paystubs, etc. Cancelof

17. Family Composition

	Last name	First Name	Relationship to Head of Household	Sex	Dat e of Birth
Head of Household
2
3
4
5
6
7
8

Any other members, please list below:

18. Pre-Inspection Questionaire

	...
Number of Bedrooms
Number of Bathrooms
Year home was constructed
Is there an attic?
Is there a basement?
Has your roof been replaced int he last 10 years? If, so, when?
Does your home have an attached garage?
Does your home have a sump pump?
Where is the hot water heater located?
In which room is your breaker box?
How many proches or decks does your home have?

19. What type of heat?

Boiler/ radiatorsForced AirBaseboard heaterswood burnerSpace heaters (portable heaters, kerosene, or electric)
If you need to explain, do so here
20. The Exterior of your home is:

BrickAluminum SidingVinyl SidingWood SidingStuccoMultiple
If you need to explain, do so here

21. Please list any issues in applicable areas of the home that need to be evaluated/repaired below (flooring, windows, wall, plumbing, electrical, windows, doors, etc.)

	Repairs
Kitchen
Bath 1
Bath 2
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Attic
Basement
Exterior Issues
Please list any Accessibility Modifications needed?
How many widnows are in the home

If any other repairs are needed, list them here. *
The HOME REPAIR Program Pre-Screening process requires you to provide proof of ownership (Deeds, Titles, Bill of Sale, etc), income (Social Security Statements, Paystubs, Pension/Retirement, Bank Statements, etc.), and emergency situations (Citations, Notices, CYS Documentation such as an Action Plan, Contractor's Letter, etc). If you have not done so already, we ask that you please upload the documentation required to determine eligibility.

Browse Files

Cancelof
ATTESTATION:

My signature below certifies that the answers to the above statements are true and correct.

If an applicant is determined to be initially eligible after this pre-screening, the applicant will be required to submit a full application to determine HOME program eligibilty. At a minimum, the applicant will also be required to submit documentation regarding monthly income, verification of ownership (typically a deed), proof of homeowners insurance, and proof of paid property taxes . Additional documents may be requested by the HOME program staff to determine eligibility.

Once a completed full application and all supporting documents are received and approved, the applicants name will be placed on the waitlist.
Signature

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Date
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