Housing Rehabilitation Waiting List
Name of applicant
*
First Name
Last Name
Names listed on property deed:
*
Property Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Total number of individuals in the household
*
Total number of adults in the household
*
TOTAL household GROSS income
*
Year the home was built
*
Is your home a trailer?
*
Yes
No
Do you have a mortgage on your home
*
Yes
No
Do you have a reverse mortgage on your home
*
Yes
No
Are you current on your taxes?
*
Yes
No
Do you have a current Homeowners Insurance Policy?
*
Yes
No
Is there mold in the home?
*
Yes
No
Please tell us about some of the repairs you home may be in need of
*
If you would like to upload photos of the areas of the home you are seeking assistance for, please upload them here
Browse Files
Drag and drop files here
Choose a file
Cancel
of
By submitting this application for assistance from the Pike County Human Services I hereby acknowledge and agree to the following terms and conditions: Accuracy of Information: I certify that all information provided in this application and in any attached documents is true, accurate, and complete to the best of my knowledge. I understand that any false statements or deliberate omissions may result in the denial of my application or termination of any assistance granted. Use of Information: I authorize Pike County Human Services and its agents to use the information provided in this application for the purpose of evaluating my eligibility for assistance. This may include verifying information with third parties, such as employers, landlords, and government agencies, as necessary. Privacy and Confidentiality: I acknowledge that Pike County Human Services is committed to maintaining the privacy and confidentiality of my personal information. Information provided in this application will be used solely for the purpose of assessing my need for assistance and will not be disclosed to any unauthorized parties without my explicit consent, except as required by law. No Guarantee of Assistance: I understand that submission of this application does not guarantee that I will receive assistance. Assistance is provided based on the availability of funds, the eligibility criteria of the program, and the demonstrated need of the applicants. Decisions made by Pike County Human Services regarding the distribution of assistance are final. Changes in Circumstances: Should my circumstances change after the submission of this application; I agree to notify Pike County Human Services promptly. This includes changes in income, family size, address, or any other information that could affect my eligibility for assistance. Terms and Conditions: I agree to comply with all terms and conditions of the assistance program, should I be selected to receive aid. I understand that failure to comply with program requirements may result in the termination of assistance. Release of Liability: I hereby release and hold harmless Pike County Human Services, its directors, officers, employees, and agents from any liability, loss, or damage arising from my participation in the Pike County Human Services or from the denial of my application. By signing below, I acknowledge that I have read, understand, and agree to the above terms and conditions. I also understand that this application is subject to review and approval by Pike County Human Services and that I may be asked to provide additional information or documentation as part of the review process.
*
Date
*
-
Month
-
Day
Year
Date
Save
Submit
Pike County Human Services
(570) 296-3434
Should be Empty: