Mail or fax completed form to:
Habitat for Humanity of Archuleta County
POB 2827
Pagosa Springs, CO 81147
Neighbors Helping Neighbors Ph. 970-264-6960 Fax 888-842-1180
Home Repair Program
For Office Use Only
Preliminary Application
Date Received:
Neighbors Helping Neighbors is a program of Habitat for Humanity of Archuleta County that does home painting and
repairs for low- income homeowners who need assistance to do necessary work. Please complete this First Application as
best you can to help us understand your repair needs. Call 970-264-6960 with any questions.
SECTION 1 - Homeowner Information
Legal Name of Homeowner(s):
Age(s):
Home Address:
City:
Zip:
Email:
Mailing Address (if different from home address):
Telephone Numbers:
Number of Years at Address:
Name of Neighborhood:
Home:
Cell:
Please include area code
Work:
Is anyone in your household a veteran?
Yes No
Name ___________________
Is anyone in your household currently in the military? Yes No
Name____________________
SECTION 2 - Special Needs
Yes
Is the homeowner or anyone in the home disabled?
No
If yes, indicate the type of disability below (check all that apply, please describe if “other”):
Uses a Walker, Cane or Crutches
Loss of Limb
Is translation needed?
Wheelchair Bound
Mentally Disabled
Yes
Blind
Hearing Impaired
Other: _________________________________
No
If yes, what language: __________________
SECTION 3 – Requested Repairs
What needs to be done at your home and why? Describe in as much detail as you need. Please consult Section 5 on
page 3 if you need assistance in thinking about your repairs.
Neighbors Helping Neighbors: Preliminary Application
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SECTION 4 – Your Contribution
Are you willing to make a contribution to this project? If so, in what ways (for example time, labor, material, money,
etc.)?
SECTION 5 - House Information / Exterior
HOUSE INFORMATION
Place a large “X” over the house (below), which most
resembles the size of your house.
Year Purchased: ____ Year Built: __________
Last Painted: _______ Square Feet: ________
Parts of house and garage that need painting:
House siding
House trim (around doors, windows, overhangs,
etc.)
Garage siding
Garage trim (around doors, windows,
overhangs, etc.)
Other __________________________
House Exterior
Siding
Trim
wood
wood
brick
vinyl
shakes metal
stucco
painted stucco
asbestos/slate
aluminum
vinyl
Garage Exterior
Siding
Trim
wood
wood
brick
vinyl
shakes metal
stucco
painted stucco
asbestos/slate
aluminum
vinyl
Repairs needed on exterior:
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
__________________________________________________
Signature of Homeowner
___________________________________
Date
________________________________________________________________
Name of person completing this form if not the homeowner (Print and Signature)
Neighbors Helping Neighbors: Preliminary Application
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SECTION 6 - Requested Repairs
Briefly describe the type of work you would like done on your home. Attach a separate piece of paper if there is not enough space to
list all repairs. Remember that the items listed below will be considered for repair, but the final decision on what work can be done
with our time and financial resources will be made at the discretion of Neighbors Helping Neighbors. The work done by Neighbors
Helping Neighbors will focus on warmth, safety and independence. Our volunteers are not professionals and may not be able
to make all repairs.
Please print
Area of Repair
Description
Accessibility Modifications. Examples:
wheelchair ramp, bathroom grab bars,
accessible shower stall, etc.
Carpentry Repairs. Describe problems with
doors, floors, porches, steps, walls, ceilings,
etc. Indicate places in house needing repair.
Electrical Repairs. List rooms where wall
outlets, switches and light fixtures do not work.
Plumbing Repairs. Describe sink, tub or
toilet leaks, etc.
Roofing Repairs. Identify where roof leaks.
Painting. List all interior rooms that require
painting and any exterior painting
requirements.
Appliances. Identify appliances such as stove,
refrigerator or hot water heater that do not work
or need repair.
Doors and Windows. Describe repairs
required, including locks, glass, frames,
weather-stripping, etc.
General Cleaning. Indicate if there is
cleaning and/or trash removal required.
Identify if yard work is necessary.
Other. Identify other repairs requested but not
listed above.
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Please add any additional information that would help us in understanding your request.
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