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HOME REPAIR FORM

If you are interested in our program, please complete and submit the inquiry form. If you have already submitted any inquiry either online, or by mail, no further action is required of you at this time. *This form requires an email address. If you do not have access to email, please request a form by mail by calling us at (610) 278-7710 xt. 130.

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​Fields marked with an * are required. This form requires an email address. If you do not have access to email, please request a form by mail by calling us at (610) 278-7710 xt. 130.

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​You may also request a hard copy of this form by calling us at (610) 278-7710 xt. 134. If you do not have access to email, fill in “N/A”.

County

Street address of home in need of repair

Current mailing address - if different than the permanent address (if it’s the same, type “same”)*

Is your home currently insured? If “no” you are not eligible for this program
Has Habitat MontDelco completed work on your home before?

If Habitat MontDelco worked on your home before, when was the approximate date of work? (please mark “N/A” if Habitat MontDelco has not worked on your home before.)*

This program has a maximum annual income allowed for program participation that is based on household size. Does your household have a total gross household income below the levels listed in the chart below?
HOUSEHOLD INCOME CHART_home repair_5.1.2024.png
The WHRP Application can be completed in two different ways. Please review each selection below and choose the option that you prefer: *
Optional Fields * Due to specialized funding sources, we like to offer the optional opportunity for homeowners to identify themselves or members of their household, as one or more of the following:
I affirm that I have read and understand all the information about Habitat MontDelco’s Home Repair programs(s) published on the Habitat MontDelco website. *
I both understand and affirm that Habitat MontDelco’s home repair programming may require some form of repayment plan or property lien, depending on the requirements of the funding source(s) used. I further understand that if I am not comfortable with a repayment requirement associated with an application opportunity, I am welcome to decline and wait for the next opportunity. *
I understand that this online program inquiry form is not the same as a program application and that Habitat for Humanity of Montgomery and Delaware Counties will mail me a program application directly when funding is available and applicable to my home’s needs. *
Thanks for submitting!
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