Habitat Home Repair Program Pre-Qualification Form

This is a pre-screening questionnaire, not a final application for Home Repair.
This form is to help determine if the Habitat for Humanity program might be right for your household. It is one step in the process of applying for a home repair.

Equal Housing Opportunity: We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status or national origin.

Applicant Name (Homeowner of Record)
Applicant Address
Applicant Contact Info
Co-Applicant Information
Residency and Property Questions
Have you lived or worked in Pinellas County for at least one (1) year? *

Are you the homeowner? *

Are all mortgage and property tax payments current? *

Are there any Code Violations ? *

Do you have homeonwers insurance? *

Have you filed an insurance claim for repairs? *

Are there any liens on the property?

Is the property a mobile home? *

Financial Information Questions
Have you had verifiable and continuous income for at least 1 year? *

Have you ever filed for bankruptcy? *

Do you have any debt in collections? *


List your total monthly income from applicant and co-applicant (if applicable). Please list each different type of income along with the monthly amount:

Gross Monthly Income
What was earned monthly before taxes/deductions
If N/A leave as 0
If N/A leave as 0
If N/A leave as 0
If N/A leave as 0

Monthly Expenses

List your monthly expenses, including credit cards, car payments, loans such as furniture or student loans, or any other debts (do not include utilities)

Monthly Expenses
If N/A leave as 0
Please provide total amount of other loans in dollars
If N/A leave as 0
If N/A leave as 0
If N/A leave as 0
If N/A leave as 0
Residence and Repair Questions
(Do not include applicant or co-applicant in this section)
Is anyone in the household 65 or older? *

Is anyone in the household active military or veteran? *

Are you on the sexual predator list or have you had a drug trafficking conviction in the last 3 years? *

Form Submission Statement

By submitting this form, I affirm that the information on this form is true. I understand that providing false information could cause me to be disqualified from the Habitat program. I understand that someone from Habitat for Humanity will contact me with the results from this questionnaire, and that I may be invited to complete a homeowner application.

* After clicking submit you will be redirected to a thank you page, if you do not see this page your form has not been submitted. In this event please search for highlighted red entry errors*