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Substandard Structure Repair Assistance Program Application

Section 1. Applicant Information

Name:   

Property Address of Repairs: 

City:       State:       Zip Code: 

Work Phone:   Home Phone:   Cell Phone: 

E-mail: 

Are you the property owner:  Yes      No

Mailing Address (if different): 

City:       State:       Zip Code: 


Section 2: Description of Service Request and Contractor Information

Please check all that applies to this request (provide a short description of the request at the bottom.  Include quote and scope of work).  Property owner must also provide sufficient evidence that application is being made for qualifying repair.

 Structural Framing
 Roofing
 Plumbing
 Electrical
 Heating & AC
 Restroom Mobility - Showers, Faucets, Toilets, Grab Bars



Contractor Information

Name: 

Address: 

City:       State:       Zip Code: 

Work Phone:       Email: 



*Please attach proof of of ownership with this application (Deed, title or mortgage loan statement)

(To select multiple files, click "Choose Files," then use the Shift or Ctrl Key to select all documents you wish to upload. You will not be able to upload your documents one at a time.