Housing Preservation Grant

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USDA -HPG application

United Way of Western Crawford County - Community Improvement Center

415 Chestnut Street, Meadville, PA 16335

(814) 337-1251

Applicant Name *

Residential Address (proof of homeownership required after application review - *mobile home owners must also own lot property) *

Contact Number *

Project Request (Be specific and prioritize request if multiple projects.) *

Have you applied for Community Improvement Center or Make A Difference Day assistance prior to this application? *

Yes

Maybe

If so, when was the project completed?

YYYY

List all members of household (relation to homeowner) gross annual income/income source (*proof of income required after application review)

Example:

John Smith (homeowner) $23,700/year - Social Security;

Jane Doe (daughter) $14,600/year - employed at X store

Are you able to purchase/pay for part of the materials? *

Yes

Maybe

Are you receiving service assistance from any human service agency? *

Yes

If so, what agency?

Are you eligible for veteran benefits? *

Yes

Please describe the medical/economic need related to the project request. *

Applicant Age:

Applicant Gender:

Male

Female

Prefer not to say

Other:

Clear selection

Applicant Ethnicity:

Hispanic or Latino

Non Hispanic or Latino

Clear selection

Applicant Race:

White

Black or African American

American Indian/Alaska Native

Asian

Native Hawaiian or Pacific Islander

Other:

Clear selection

By submitting this application you are stating that all the information provided is accurate to the best of your knowledge and you understand that submission of an application does NOT guarantee that your application will be accepted/approved.

Submit

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