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Eligibility Screening Form

  1. Are you the homeowner?*

  2. Is this your primary residence?*

  3. Was your property built before 1978?

  4. Is anyone in your household...

    (Check all that apply)

  5. (Include everyone's income. Include income such as disability, Social Security, etc.)

  6. (Examples include plumbing, roof, need handicap ramp, etc.)

  7. Thank you for your submission! You will be contacted soon. If you have questions in the meantime, please call (336) 883-3349.

  8. Leave This Blank:

  9. This field is not part of the form submission.