Home Repair Application - Gateway Wellness Foundation

This online application does not allow the user to save a partially completed application and come back at a later time to complete it. The application must be completed in one sitting.

First Name

Last Name

Street Address

City

State

Zip Code

Primary Phone

Cell Phone

County of Residence

Do You

How Many People Live in the House?

How Many Years Have you Owned the House?

RP’s program is designed to address critical, urgent needs in the home. Our program is not designed to address cosmetic issues. Please list the needed repairs and why they are critical to your home. If you need more space, please continue the list on a separate sheet of paper

Need 1

Need 2

Need 3

I specifically acknowledge that the above information is complete and true to the best of my knowledge.

Applicant Name

Date

Own
Rent
Have a Life Estate
Live in a house owned by another family member