Home Repair Request Form Contact Us CONTACT INFORMATIONName* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number*Email HOUSEHOLD INFORMATIONAnnual Household Income:* How many individuals over 18 years of age live in the household?* How many children, 17 years of age or younger, live in the household?* Age of the Home:* Length of years of ownership of home:* Type of Home* Single Family Duplex Condo Mobile Home Modular Home Are you or anyone living in the home a veteran of the United States Armed Forces? Yes No Are you a Consumers Energy Customer? Yes No Year roof was last replaced or repaired? PROGRAM ELIGIBILITYPlease answer the questions below to provide Habitat with information about your current housing status, ability to pay for repair services and your willingness to partner with our organization.Homeownership (check all that appy)* I am the legal owner of my home, my name is listed on the property deed I am NOT the homeowner; I am renting the home I have a land contract I am renting to own The home is my primary residence I am current on my mortgage or current on a payment plan for delinquent payments I am current on my property taxes or current on a payment plan for delinquent taxes I am currently have homeowners insurance and am current on the policy Ability to pay (check all that apply): I understand that some programs Habitat uses may charge a reasonable fee for the services I am approved for I understand my fee will be reviewed with me and agreed upon prior to project approval Willingness to Partner (check all that apply): I am willing to suppy all necessary paperwork as required by the programs I am willing to complete the required number of sweat equity hours for my home repair within the organization I am willing to display partnership materials such as a lawn sign How old is your furnace?* 15 years old or older Under 15 years old My furnace uses (check all that apply): Natural Gas Propane Wood Pellets Please describe the home repair need:*Pictures of home repair needed? Please choose one of the following.* I can provide pictures of item needing repair I need someone to come and take pictures of my repair request for me? Upload Picture of Requested Repair Drop files here or Select files Max. file size: 2 GB. Have you requested assistance from another agency or church?* Yes No If you answered yes to the above, which agency or church did you work with?*How did you hear about Midland County Habitat for Humanity's repair program?*
