Home Repair Intake Form

I understand that by submitting this intake, I am authorizing Habitat for Humanity of Clallam County to evaluate my need for the home repairs. I understand that the evaluation will include a home assessment by Habitat's representatives. I give permission for photos to be taken of my home. I have answered all of the questions on this form truthfully. I understand that if I have not answered the questions truthfully, my request may be denied and that even if I have already been selected to receive a Habitat repair, I may be disqualified from the program. The original or a copy of this form will be retained by Habitat for Humanity. I hereby authorize Habitat for Humanity of Clallam County to conduct credit and/or other background checks in conjunction with this request for service.

Neighborhood Revitalization-Home Repair Intake Form

Fields marked with * are required

Complete the following if you are not the Homeowner, but are assisting the Homeowner in completing the Intake Form:
Layout Settings