DEKALB COUNTY SPECIAL PURPOSE HOME REPAIR PROGRAM

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PRE-APPLICATION CARD
DEKALB COUNTY SPECIAL PURPOSE HOME REPAIR PROGRAM
DEKALB COUNTY COMMUNITY DEVELOPMENT DEPARTMENT

THIS PROGRAM IS FUNDED BY THE U.S. DEPARTMENT of HOUSING & URBAN DEVELOPMENT
COMMUNITY DEVELOPMENT BLOCK GRANT

First

Middle

Last

Suffix

Name

Address

Address 2

City

State

ZIP

Email Address

Home Phone

Work Phone

Cell Phone

Date Of Birth

Household Composition (How many persons live in your home?)

Are You Disabled

YES

Other…

Name on Property Title

How Long Have You Owned Your Home?

Have You Ever Received a Grant or Loan to Repair Your Home from DeKalb County?

YES

Other…

If Yes, When

Source Of Income

(EXAMPLES Social Security, Pensions, Annuities, VA Benefits, Employment, Income from Assets, Checking, Savings and Any other source of income)

Annual Gross Income Of Household Before Deductions (such as taxes & insurance)

(include total income of ALL persons 18 and over living in the home)

*HOMEOWNER’S WHO PREVIOUSLY RECEIVED HOMEOWNER REPAIR OR REHABILITATION ASSISTANCE, ARE NOT ELIGIBLE FOR THIS PROGRAM *

DeKalb County - Community Development Department must receive this submission before 3PM on Friday, February 2, 2024.

Section 1001 of Title 18 of U.S. Code makes it a criminal offense to make willful false statements or misrepresentation to any Department or Agency in order to receive federal funds.

Signature

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DEKALB COUNTY SPECIAL PURPOSE HOME REPAIR PROGRAM

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