Community Development Pre-Application DeKalb Cares Plumbing Repair Project

First Name

Last Name

Date of Birth

Address

Address?

City/Town?

State/Province? - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

ZIP/Postal Code?

How long have you owned your home?

How many persons live in your home?

Phone Number

Type - Type -HomeOfficeCell

Phone

Are you disabled?

Yes

No

Title of property in the name of?

Have you ever received a grant or loan to repair your home from us? Yes/No if yes

Yes

No

When?

Source of Income

Annual gross income of household before deductions

(i.e., taxes & insurance)

*HOMEOWNERS WHO PREVIOUSLY RECEIVED HOMEOWNER REPAIR OR REHABILITATION ARE NOT ELIGIBLE FOR THIS PROGRAM*Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency to receive federal funds.

DeKalb Community Development Department
178 Sams Street, Suite A-3500
Decatur, GA 30030