Home Preservation Interest Form

First Name

Last Name

Email

Phone

Street

City

Zip Code

State

Which county do you currently live in? San Francisco Marin San Mateo Alameda Contra Costa Napa Santa Clara Solano Sonoma Other

How many people are in the household? (Include all adults and children, living at least 50% of their time in the home.) 1 2 3 4 5 6 7 8 9 10

What was the total income for all household members in the previous year? This can be calculated by adding together each household member’s tax returns. If a household member did not file taxes, please estimate their annual income.

Have you lived in your home for more than 10 years? YesNo

Roofing repair/replacement YesNo

Siding repair/replacement YesNo

Window repair/replacement YesNo

Accessibility Upgrades YesNo

Doors YesNo

Electrical repairs YesNo

Fencing YesNo

Free Home Energy Assessment YesNo

Furnace YesNo

House Paint (Exterior) YesNo

House Paint (Interior) YesNo

Landscaping YesNo

Plumbing YesNo

Porch YesNo

Rain Gutters YesNo

Ramp YesNo

Stairs YesNo

Water Heater YesNo

Primary Applicant's Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Pacific Islander White American Indian AND White Asian AND White Black or African American AND White American Indian AND Black Other multiple race Choose Not to Respond

Primary Applicant's Ethnicity Hispanic or Latino Not Hispanic or Latino Choose Not to Respond

What is your preferred language?

Is the primary applicant a military member or veteran? Yes No

Does the primary applicant have a disability? Disabled Not disabled Choose Not to Respond

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