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?
Which county do you reside in?
Can you provide proof of citizenship or Permanent Residency Status?
Date of Birth
Marital Status *
* Legal Documentation May be required.
Are you a Veteran or a current member of the U.S. Arm Forces?
If yes, were you honorably discharged?
If yes, are you disabled?
Please list the co-applicant, if applicable:
Street Address (if different from above)
Date of Birth
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.
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.
By typing your name in the box above you understand that it servers as a legal signature.
Co-Applicant (if applicable)