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2. Applicant's Full Name*
3. Today's Date*
   Today's Date
5. Home Address*
   Address must be within the City limits to qualify.
7. City
8. State
9. Zip Code
11. Phone Number*
    Enter a phone number by which you can be contacted.
13. Hurricane Damages*
    -- Select One --YesNo

    Is this application for hurricane damages?

15. Do you own the property?*

    1. Yes

    1. No

    i.e., Is your name on the deed?  

    NOTE- THIS PROGRAM IS NOT FOR LEASED PROPERTIES

16. Do you live in the property as your permanent place of residence?*

    1. Yes

    1. No
18. Are your property taxes current?*

    1. Yes

    1. No
19. Is there a mortgage (1st or 2nd) on the property?*

    1. Yes

    1. No
21. Are your mortgage payments current?

    1. Yes

    1. No
23. Do you have homeowner's insurance?*

    1. Yes

    1. No
25. Do you own any other properties?*

    1. Yes

    1. No

    This includes vacant land or out of state properties.
26. How many members live in the home, including yourself?*
28. What is the gross amount of monthly income from all sources, for all household members?*
    This includes Supplemental Security Income (SSI), social security benefits, retirement pension, workers' comp, alimony, child support, unemployment benefits, and wages.
30. What is your approximate total gross annual household income? *
    This includes all sources of income from all household members.
32. Repairs Needed*
    Please explain the repairs you believe are needed to your home to bring it up to code. Please be advised that the program only provides repairs that make the home meet minimum Housing standards; it does not address cosmetic issues that do not affect the safety or welfare of the occupants.
34. Have you ever requested assistance from the city before?*

    1. Yes

    1. No
35. Have any additions or alterations been made to your home that are not original to the home?*

    1. Yes

    1. No
37. Are there any special notes or circumstances that you would like for us know about with regard to your request?
39. Email Address*
    Please provide us your email address for confirmation purposes.
41. Do all owners listed on the deed reside at the residence?*

    1. Yes

    1. No
42. Are there any household members that are considered a special needs person or are disabled and receiving Supplemental Security Income (SSI) or Social Security (SS) disability?*

    1. Yes

    1. No
44. Have you received notice of foreclosure on your property?*

    1. Yes

    1. No
45. Are you aware of any outstanding liens on your property other than your mortgages?*

    1. Yes

    1. No

    (e.g. Internal Revenue Services (IRS), City, County, Code Enforcement fines, etc.)
47. Do you have any outstanding citations issued by the code enforcement department?*

    1. Yes

    1. No
48. Are you and any co-applicant US citizens?*

    1. Yes

    1. No
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit Submit and Print

* indicates a required field