West Anniston Healthy Homes Pre-screening Form

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This prescreening tool will help us to determine if you pre-qualify for our Healthy Homes project. If you are qualified you will be contacted by MAIL to complete a full application. Thanks! See income requirements and documentation requirements below.

Healthy Homes Production Income Threshold

Healthy Home Required Documentation

West Anniston Foundation Healthy Homes

First Name *

Last Name *

Address (Include City, State, Zip Code) *

Phone Number *

Email *

3. Do you own or rent your home? *

Own

Rent

4. Do you have a mobile home? *

Yes

5. Property Information: Name of Property Owner (if different from applicant), Contact Phone Number (if different from applicant), Email Address (if different from applicant), Physical Address of the Property:

6. What is your total annual household income (we will need proof on income once your screening is approved, e.g., tax forms)? See Example Provided *

Less than $15,000

$15,000 - $30,000

$30,000 - $50,000

Greater than $50,000

7. How many people live in your household? *

8. How many children live in your household? *

9. Are there individuals over the age of 62 in your household? *

Yes

10. Are there individuals with a disability (physical or intellectual) in your household? *

Yes

11. What health concerns do you and/or other members of your household have? Check all that apply *

Asthma

Allergies

Memory loss/ complaints

Cancer

Kidney disease

Liver disease

Lupus

Multiple sclerosis

Autism

Attention deficit disorder

Depression/ anxiety

Not Applicable

Other:

Required

List Top 5 Concerns in Your Home *

Submit

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