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SAFE HOME INITIATIVE: Resident Application
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* Indicates required question
Email
*
Your email
Full name of applicant
*
Your answer
Address
*
Your answer
Contact phone number
*
Your answer
Do you rent or own your home?
*
Rent
Own
If you rent, what is the name and contact information of the landlord (name, phone, and email address)?
*
Your answer
How many people reside in your home?
*
Your answer
What are the ages of those residing in the home?
*
Your answer
What is the ratio between your average monthly gas and electricity bill and your income?
*
Your answer
Does your household receive government assistance of any kind?
*
Yes
No
What is your top concerns with your home?
*
Comfort
Indoor air quality and health
High energy bills
Safety
Other:
Required
Does anyone residing in the home have underlying health conditions? (Asthma, COPD, Bronchitis, Cystic Fibrosis, Auto-immunity, Chronic Inflammatory Response Syndrome, Cancer, or other condition)
Your answer
How long has it been since the last improvement was made on your home and what was that improvement?
Your answer
Now it's time to tell us your story. Why are you applying to the Safe Home Initiative? Here are some questions to help you get started: 1) What it is like to live in your home in its current condition? 2) Describe your primary concerns in more detail. 3) Explain how the condition of the home impacts those who live there.
*
Your answer
What are you hoping to achieve if your home is selected for home improvement upgrades?
*
Your answer
Now, we'd like to know a little bit more about your home.
What type of home do you live in?
Single family detached
Duplex
Condo/Townhome
Mobile home
Apartment
Clear selection
How many bedrooms does your home have?
*
1
2
3
4
Other:
How many bathrooms does your home have?
*
1
2
3
Other:
Foundation type:
*
Basement
Crawlspace
Slab (no basement or crawlspace)
I live in a condo, townhome, or apartment
Other:
Age of the home:
Your answer
Number of HVAC units located outside the home:
1
2
3
Other:
Clear selection
Thank you for completing the application!
Applications are reviewed on the 15th of each month. Funding is awarded after an assessment of the home and is based on need as well as available funds. For additional questions, please contact us at 615-477-2822.
A copy of your responses will be emailed to the address you provided.
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