EmailMeForm
Aging in Place
Pre-Application Eligibility Questionnaire
Please list what repairs are needed
Please review our income guidelines. Your income must not exceed the maximum range for your family size listed below.
# Living in Home - Claiborne - Grainger - Hamblen
1 - $21,060 - $21,060 - $21,420
2 - $24,060 - $24,060 - $24,480
3 - $27,060 - $27,060 - $27,540
4 - $30,060 - $30,060 - $30,540
5 - $32,520 - $32,520 - $33,000
6 - $34,920 - $34,920 - $35,460
7 - $37,320 - $37,320 - $37,920
8 - $39,720 - $39,720 - $40,320
Have you lived and/or worked in Hamblen, Grainger or Claiborne County for at least one year?
Yes
No
Which county do you reside in?
Hamblen
Grainger
Claiborne
Can you provide proof of citizenship or Permanent Residency Status?
Yes
No
Contact Information
Full Name
*
Street Address
City
State
ZIP
Date of Birth
Age
Marital Status *
Married
Unmarried
Divorced
Legally Separated
* Legal Documentation May be required.
Are you a Veteran or a current member of the U.S. Arm Forces?
Yes
No
If yes, were you honorably discharged?
Yes
No
If yes, are you disabled?
Yes
No
Home Phone
Cell Phone
Work Phone
Please list the co-applicant, if applicable:
Co-Applicant
Street Address (if different from above)
City
State
ZIP
Date of Birth
Age
List ALL sources of income. You must include source of income, amount BEFORE TAXES, and times paid per month (weekly, biweekly, etc.)
Other acceptable sources of income are: Social Security, Disability, Retirement, and Child Support
Documentation for these will be required and will be verified by Habitat Staff.
Example:
Jane Doe, Company Name, $350, Biweekly
Release: By my signature, I affirm that all of the information provided in this document is true. I understand that the information provided will be kept confidential. I further agree that false statements on this form will eliminate my eligibility to participate in this program.
Applicant
*
By typing your name in the box above you understand that it servers as a legal signature.
Co-Applicant (if applicable)
Date Time
MM
/
DD
/
YYYY