Home Repair Initial Intake Form

Property owner(s) name *

Address *

Phone *

Email *

Is the house a single or a double? *

Number of people in the house? *

Number of people receiving an income? *

Estimated total annual income for household (all sources) *

Are property taxes (City & County) current? *

Are water bills current? *

Are user fees (garbage) current? *

Do you have homeowner’s insurance? *

Age of owner(s)? *

If over 62, do you need assistance with any routine requirements of daily living? * YesNo

If you answered Yes, Please explain:

Summarize the work that you think needs to be done on the house. *