Repair Inquiry Form

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Who We Are
What We Do
Volunteer
Donate
ReStore
Contact Us
- Contact
- Stay Connected

Who We Are
What We Do
Volunteer
Donate
ReStore
Contact Us
- Contact
- Stay Connected

Repair Inquiry Form **This is not an application**

Homeowner Information:

Name of Homeowner *

First

Last

Name of Co-Homeowner

First

Last

Address (Mailing and Physical) *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Are you or someone in your household a Senior (62 years old and older)? *

Yes
No

Are you or someone in your household a Veteran? *

Yes
No

Are you or someone in your household disabled? *

Yes
No

Family size? *

Please list all HOUSEHOLD MEMBERS living in the home, including their age and relationship to the homeowner. *

List ALL sources of monthly income, including the income from ALL houshold members, regardless of age. sources including, employment, SSI, SSDI, Child Support, Kinship care, retirement, uempoyment, SANP benifets, etc. *

List ALL monthly debt payments, including but not limited to utility payments, auto loans, personal loans, credit care bills, medical bills, student loans, childcare, taxes, insurance, etc. *

To your knowledge, do you have any major credit delinquencies (past due payments or bills in collections?) If yes, please explain. *

Information about your home:

Is your home a: *

How much are you currently paying each month for housing? *

When did you purchase your home? *

Do you currently have a mortgage lien on your home? *

Yes
No

Do you have homeowners insurance? *

Yes
No

Have you ever received a 504 Direct loan or Grant from the USDA Rural Development? *

Yes
No
Not sure

Are you currently enrolled in RMDC's Energy assistance program, LEIAP? *

please describe the top four priority repairs you would like to see addressed? *

Please upload photo(s) of the repairs needed.

Click or drag files to this area to upload. You can upload up to 10 files.

if your photos will not upload, please email them to; celliott@helenahabitat.org

I/We the undersigned, understand that this is not an applicaiton for repairs, Only an inquiry to Helena Area Habitat for Humanity Repair Program. *

Yes
No

Homeowner's Signature *

Administrative Office:

432 N Last Chance Gulch Suite R
Helena, MT 59601

Mailing Address:

PO Box 459
Helena, MT 59624

ReStore:

1320 Market Ave.
Helena, MT 59602

Phone/Email:

info@helenahabitat.org
(406) 449-4663