Aging in Place Pre-Application

If you are interested in applying for our Aging in Place pilot program and you believe you qualify, we encourage you to fill out the application request form below. If you would like assistance completing this form, please contact Holly at 507-388-2081 ext. 204.

Note: HFHSCM will not proselytize, nor will HFHSCM work with entities or individuals who insist on proselytizing as part of their work with HFHSCM. This means HFHSCM will not offer assistance on the expressed or implied condition that people must adhere to or convert to a particular faith or listen and respond to messaging designed to induce conversion to a particular faith.

Your Contact Information

First Name *

Last Name *

Email *

Address Line 1 *

Address Line 2

Phone

City *

State *

Zip *

Co-Applicant Full Name: The maximum length for the field Co-Applicant Full Name: is 500 characters.

Co-Applicant Phone Number: The field Co-Applicant Phone Number: must be a phone number.

Co-Applicant Email Address: The maximum length for the field Co-Applicant Email Address: is 500 characters.

Household yearly income? * The field Household yearly income? is required.

Total number of household members? * The numeric field Total number of household members? is required.

Number of household members below the age of 18? * The numeric field Number of household members below the age of 18? is required.

How did you hear about Habitat for Humanity? * The field How did you hear about Habitat for Humanity? is required.

Demographics

PLEASE READ THIS STATEMENT BEFORE ANSWERING THESE QUESTIONS:

These questions help Habitat for Humanity South-Central Minnesota measure our compliance with the federal Equal Credit Opportunity Act, which prohibits unlawful discrimination. You ARE NOT required to provide this information.

We will not take this information (or your decision not to provide this information) into account in connection with your application. The law provides that a creditor may not discriminate based on this information or based on whether or not you choose to provide it. If you choose not to provide the information, we may note it by visual observation or surname.

Race:

Gender:

Age Range:

Marital Status:

Education: