Home Repair and Rehabilitation Application

SNAP
3102 W. Fort George Wright
Spokane, WA 99224
(509) 456-7111
Fax: (509) 534-5874

Housing Improvements

Home Repair and Rehabilitation Application

You must own or be buying your home/mobile or manufactured home to be eligible for this program.

Name: *

Property Address: *

City: *

State: *

Zip Code: *

Phone 1: *

Phone 2:

E-mail Address:

What type of home do you have?: *

Stick Frame

Mobile/Manufactured Home on your land

Are your mortage payments current?: *

Yes

Are your property taxes current?: *

Yes

Do you have homeowner's insurance?: *

Yes

Do you have a second mortgage?: *

Yes

Any outstanding judgments or liens?: *

Yes

Is a commercial business run out of the home: *

Yes

Household Member Information

Please complete for all household members

Full Name: *

Date of Birth: *

Ethnicity: *

Years of Education: *

Disabled?: *

Yes

Veteran?: *

Yes

Medical Insurance?: *

Yes

Type of Income & Amount: *

Household Member Information

Household Member #2

Full Name:

Date of Birth:

Ethnicity:

Years of Education:

Disabled?:

Yes

Veteran?:

Yes

Medical Insurance?:

Yes

Type of Income & Amount:

Household Member Information

Household Member #3

Full Name:

Date of Birth:

Ethnicity:

Years of Education:

Disabled?:

Yes

Veteran?:

Yes

Medical Insurance?:

Yes

Type of Income & Amount:

Household Member Information

Household Member #4

Full Name:

Date of Birth:

Ethnicity:

Years of Education:

Disabled?:

Yes

Veteran?:

Yes

Medical Insurance?:

Yes

Type of Income & Amount:

Household Member Information

Household Member #5

Full Name:

Date of Birth:

Ethnicity:

Years of Education:

Disabled?:

Yes

Veteran?:

Yes

Medical Insurance?:

Yes

Type of Income & Amount:

Family Assets

Please give the values of all items listed

Checking Account:

Savings Account:

Certificates:

Money Market:

Treasury Notes:

Jewelry:

Cash value life insurance:

Vehicles:

Stocks:

Bonds:

Coins:

Other:

Do you own any real property, not including your current home?:

If you do, please list the address(es) and value(s)

Address:

Value:

Repairs needed: *

Have questions or need assistance with this form?:

RELEASE & NOTIFICATION:

This form is just a pre-application.  It will help us determine, based on the information you have provided, if we will be able to assist you.  This is not a guarantee that the work will be completed.  If you are considered eligible based on the above information, you will be asked to provide documentation to prove all of the above including but not limited to, income,social security number and address verification for all household members, copies of bank statements, appraisals for assets, and life/homeowners insurance policies.  By signing below, you acknowledge that the information you have provided is true and accurate to the best of your ability.

Applicant Signature: *

Date: *