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Thank you for your intrest in our program.  To quailify for services, you must be over the age of 60 or living with a mobility disability, have owned your home for at least 3 years and meet our income guidelines.  

Meeting qualifications does not guarantee services.  We are unable to accept on-line applications at this time.  To apply for services, please call a member of our Home Repair Team at 614-258-6392.



* - Required field.

*First name
Middle name
*Last name
Mailing Address 1
Mailing Address 2
Mailing City
Mailing State
Mailing Zip code
Physical Address 1
Physical Address 2
Physical City
Physical State
Physical Zip code
Home phone
Work phone
Work phone ext.
Cell phone
E-mail address
County
Ethnicity
Detailed Ethnicity
Gender
Date of birth

If you are not the homeowner filling out this application, enter information here.

Otherwise, enter emergency contact.

Name
Relationship
Address
City
State
Zip code
Home phone
Work phone
Work phone ext.
Cell phone

Application date
General Areas ADA
Appliances
Carpentry
Concrete
Doors
Electrical
Energy
Exterior Paint
Flooring
Furnace
Grab Bars/Handrails
Gutters
Hot Water Heater
Locks
Other
Plumbing
Roof
Ramp
Safety
Stairway/Porch
Trash Removal
Tub/Tile
Wall Repair/Paint
Windows
Yard Work

Comments:
Previous Recipient
Year:
Other Contact Name
Other Contact Relationship
Other Contact Phone
Other Contact Email
Hear About
Age
Disabilities
Please indicate any special needs:
Household Monthly Gross Income
Monthly Mortgage Payment
Head of Household
Percent of Median Income
Assistance Received SSI
SSDI
Food Stamps
VA Benefits
AFDC
Medicare
Medicaid
Home and Community Based Services
Other Governmental Assistance
Residents Living in Household (including head of household)
Name Relationship Age SSN Employed Disabled Gender Ethnicity Detailed Ethnicity Veteran
Residents Pay Rent?
If yes, how much?
Any Residents have Disabilities?
Please indicate any special needs:
Number of Pets
What kind?
Own your Home or have Tenancy for Life Agreement?
Years in Home
Current Taxes Paid?
Recent Repairs/Modifications
Veteran?