About Us
Services
FAQs
Applications & Forms
Search
Menu Menu

Application for Home Repairs

Does your home need urgent TLC? Adirondack Roots may be able to help. Complete this form to determine your eligibility for one of our home repair programs.

Please enable JavaScript in your browser to complete this form.

- Step 1 of 2

Who are you...

Type of Person *

Homeowner
Renter
Landlord

Applicant Name

Applicant Name: *

First

Last

Is there a co-applicant? *

Yes
No

Co-Applicant Name: *

First

Last

Address

Address *

Address Line 1

City

State

Zip Code

Number and taxes

Different mailing address?

Different mailing address?

Mailing Address:

Address Line 1

City

State

Zip Code

County *

Home Phone *

Cell Phone

Work Phone

Applicant Date of Birth: *

Co-Applicant Date of Birth: *

Household Information

Number of Dependents under 18 Years of Age: *

Number of Children under the Age of 6: *

Number of People in the Household: *

Have any of these children been identified as having elevated lead blood levels? *

Yes
No

What year was your house built? *

Is this a Mobile Home? *

Yes
No

Is there an occupant that has a permanent, medically documented, disability or has substantial difficulty with daily living activity because of aging? *

Yes
No

Is this the applicant/coapplicant’s primary, permanent residence? *

Yes
No

What town do you pay taxes to? *

Household Income

What is your Gross Annual Household Income? *

Employer: *

Repairs Needed (check items needing repairs, then add any specifics you can offer/explain):

repairs needed *

Heating system
Electrical systems
Plumbing systems
Walls, ceilings, floors
Roofing, chimney, gutters
Windows and doors
Foundation/basement/cellar
Insulation (walls, ceiling, roof, floor)
Stairs, cabinets, porches/decks
Wheelchair ramp or lift
Expanded Doorways due to disability
Bathroom Modifications due to disability
Relocation of Bedroom or Bathroom to 1st Floor
Kitchen Modifications due to disability
Other

Condition of home? *

No obvious repairs needed
Some repairs or maintenance needed
Needs structural or other major repairs

Voluntary Information for Monitoring Purposes

The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants on the basis of race, national origin, and sex. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way.

Racial Categories (HUD Designated)

Total # of White Applicants

White Applicants

Total # of Black/African American Applicants

Black / African American Applicants

Total # of Asian Applicants

Asian Applicants

Total # of Native Hawaiian/ Other Pacific Islander Applicants

Native Hawaiian / Other Pacific Islander Applicants

Total # of American Indian/Alaskan Native and White Applicants

American Indian / Alaskan Native and White Applicants

Total # of Asian and White Applicants

Asian and White Applicants

Total # of Black/African American and White Applicants

Black / African American and White Applicants

Total # of American Indian/Alaskan Native & Black/African American Applicants

American Indian / Alaskan Native & Black / African American Applicants

Total # of Hispanic Applicants

Hispanic Applicants

Total # of Other Multi-Racial

Other Multi-Racial Applicants

Total Numbers

Totals

Additional Information

Sex of Applicant:

Male
Female

Sex of Co-Applicant:

Male
Female

Marital Status:

Married
Separated
Unmarried: (Single, Divorced, Widowed)

Handicapped:

Yes
No

Disabled:

Yes
No

I, THE UNDERSIGNED, HEREBY CERTIFY THAT ALL INFORMATION IN THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. THE HOUSING ASSISTANCE PROGRAM OF ESSEX COUNTY, INC., IS HEREBY AUTHORIZED TO PERFORM SUCH VERIFICATIONS OF THIS INFORMATION AS MAY BE NECESSARY.

Signature *

Clear Signature

Date of Signature *

Please prove that you are human by solving the equation *

=

103 Hand Avenue
PO Box 157
Elizabethtown, NY 12932

Phone: 518-873-6888
Fax: 518-873-9102
info@adirondackroots.org

NW CHARTERED WHITE

As part of the NeighborWorks network, Adirondack Roots is among the nation’s best community development and affordable housing organizations.

© Copyright - Adirondack Roots

Link to LinkedIn
Link to Facebook