Homeowners Assistance Application

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Name of Homeowner(s):

Age: *

project? years older

Address: *

Phone:

Email: *

What type of Repair/Service: *

Do you own your home? *

Is this property insured? *

Is this property in foreclosure? *

Do you own any other properties? *

List all persons 18 years of age and older residing in the household and their monthly income:

List all persons 18 years of age or older in the home that are full-time students?

Are there any members of the household, physically able to help with the project? *

Please list the names and phone numbers of relatives or friends who will help:

Employment Income $

Rental Income $

Social Security $

Unemployment $

Retirement/Annuity $

Disability $

Supplemental Social Security $

Child Support $

Total of Above Monthly Income: $

If selected, are you willing and able to contribute ANY monies or materials to assist with the project?

If so, what will be supplied:

Name of person completing the application: *

Date: *

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Email *

People Helping People of Pinellas Park, Inc.
6250 82nd Avenue
Pinellas Park, FL 33781
Phone: (727) 276-8204
Email: php.ppark@gmail.com