Home Repairs Screening

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Please complete this screening only if you meet the following criteria:

- Must be a resident of Aransas County.
- Must be your primary residence.
- Must not have insurance that will cover the cost of repairs AND must not be able to afford to pay someone to complete the repairs.

PLEASE NOTE: To determine your eligibility for assistance, we will need documentation showing identification and proof of all income sources for your household. If you need assistance completing this form, please contact 361-450-0131 or aransashabitat@gmail.com.

Your Full Name *

Spouse/Partner's Full Name (if applicable)

Physical Address (include City, State, Zip) *

Mailing Address (include City, State, Zip) *

Email address

Phone number *

What is your total annual household income including ALL sources (wages earned, food stamps, child support, social security, etc.)? *

Please list your monthly expenses including amounts (mortgage / rent, utilities, car payment, loans, etc.): *

How long have you lived in Aransas County? *

How many people live in your home? *

How many children under 18 live in the home? *

Do you Rent or Own the home that needs repairs? *

Rent

Own

Other:

What type of structure is the home? *

Manufactured Home

House

Other:

How long have you lived in the home? *

Are you able to provide some or all of the materials necessary for these repairs? *

Some

All

None

Please describe in detail the repairs that your home needs. *

What caused the damages to your home? *

Please explain your situation. What challenges are preventing you from making the necessary repairs to your home? *

Would you be able to pay back Aransas Habitat for a portion of the cost incurred to make these repairs with a 0% interest Critical Repairs Loan? (We would work with you to determine what monthly payment amount is affordable for you.) *

Yes

Other:

Are you a US Citizen or legal permanent resident? *

Yes

Are you a US Veteran, or has anyone who lives in the house served in the US military? *

Yes

Are you, or is anyone who lives in the house over the age of 65? *

Yes

Other:

Are you, or is anyone who lives in the house disabled? *

Yes

Other:

If Yes, please briefly describe the disability:

What is your race? (check all that apply) *

AMERICAN INDIAN OR ALASKAN NATIVE

ASIAN

BLACK OR AFRICAN AMERICAN

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

WHITE

HISPANIC

Prefer not to answer

Other:

Required

How did you hear about us? *

By signing below, you certify that the information you provided is true and complete to the best of your knowledge. Any falsification could be grounds for denial or disqualification from the Habitat for Humanity Aransas County Program. *

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