Prequalification form

MOUNT CARMEL TOWNSHIP’S

OWNER-OCCUPIED HOUSING REHABILITATION PROGRAM

PREQUALIFICATION FORM

Mount Carmel Township has applied for and received a grant to fund a homeowner housing rehabilitation program within the Township. Completion of this pre-qualification form puts you on a waiting list for service.

We thank you for your participation, and ask that the Pre-Qualification Form be completed and returned to SEDA-Council of Governments. If you have any questions while completing this form, please call Sue Goddard at SEDA-Council of Governments at 1-(800)-326-9310, Ext: 7252. Your response will be confidential and used only to document the need for funding.

1. 
   Name:
   

Address:

Telephone Number: ( ) (Home)
Telephone Number: ( ) (Work)
Best time to call: Day(s): Time:
2. Do you live in Mount Carmel Township? Yes No
3. Do you own your home? Yes No

If yes, date of ownership:

4. What name is the deed listed under?
5. Is this your permanent, year-round home? Yes No
6. Your age? Spouse’s age:
7. How many people live in your household?
8. Approximate age of your house? Years

(OVER)
9. Does your total family income fall under the income limits set below? Yes No

If so please indicate which one.

TOTAL FAMILY

FAMIILY SIZE INCOME IS UNDER

1 $ 20,700

2 $ 23,650

3 $ 26,600

4 $ 29,550

5 $ 31,950

6 $ 34,300

7 $ 36,650

8 $ 39,050

Or
TOTAL FAMILY

FAMIILY SIZE INCOME IS UNDER

1 $ 33,150

2 $ 37,850

3 $ 42,600

4 $ 47,300

5 $ 51,100

6 $ 54,900

7 $ 58,700

8 $ 62,450

10. Are you in need of making major home repairs? Yes No

11. Would anyone in your household benefit from modifications to make

your house handicap accessible? Yes No

You will be contacted at a later date to set up an appointment for an intake interview.
THANK YOU FOR YOUR COOPERATION.
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SEDA Council of Governments use only
Date Received: Time Received:
Project #:
Revised 05/07/15