House Washing Program Application

Complete the application only if you have purchased a home in Cuyler/Brownville, Savannah Gardens, or West Savannah through the DreamMaker program more than five years ago.

WARNING: Section 1001 of Title 18 U.S. Code makes it a criminal offense to willfully falsify a material fact or make a false statement in any
matter within the jurisdiction of federal agency.

First and Last Name

Date of Birth

Complete Address

Alternate Contact Name and Email

Home Phone

Cell Phone

Number of years at Address

Do you have a Will?

Military Status

Marital Status

Are you blind/visually impaired?

Are you disabled?

Have you executed a power of attorney for someone to act on your behalf?

Education

Ethnicity

Race

Sex

Is there a Co-Applicant

First and Last Name

Date of Birth

Please list all persons, including yourself, who live in your house and all current sources of income for each.

Full Name

Age

Relationship

Income Amount

Income Source

Full Name

Age

Relationship

Income Amount

Income Source

Full Name

Age

Relationship

Income Amount

Income Source

Full Name

Age

Relationship

Income Amount

Income Source

Full Name

Age

Relationship

Income Amount

Income Source

Full Name

Age

Relationship

Income Amount

Income Source

Military Status

Marital Status

Are you blind/visually impaired?

Are you disabled?

Have you executed a power of attorney for someone to act on your behalf?

Education

Ethnicity

Race

How did you hear about our program?

Do you have a mortgage on the house?

Is it current?

Is the house one story?

Is the house a duplex?

By signing below, I certify that the information provided is true and accurate to the best of my knowledge. I understand that this application is part of the House Washing Program and that additional information may be required to verify my eligibility.

Date

As the applicant - I hereby certify that I am a US Citizen: (You Must Initial One)

As the applicant - I hereby certify that I am a Legal Alien: (You Must Initial One)

As the co-applicant - I hereby certify that I am a US Citizen: (You Must Initial One)

As the co-applicant - I hereby certify that I am a Legal Alien: (You Must Initial One)

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Creating housing opportunities for all.

WARNING: Section 1001 of Title 18 U.S. Code makes it a criminal offense to willfully falsify a material fact or make a false statement in anymatter within the jurisdiction of federal agency.

Subscribe To Our Newsletter

WARNING: Section 1001 of Title 18 U.S. Code makes it a criminal offense to willfully falsify a material fact or make a false statement in any
matter within the jurisdiction of federal agency.