First Name *

Last Name *

Email *

Street Address *

City *

State *

Zip Code *

County * CalumetOutagamieWaupacaWinnebago

Phone Number *

Do you own and live in your home? * YesNo

What type of home do you live in? * Single Family Detached HomeTownhomeMobile HomeOther

Please describe the repairs needed: *

Including yourself, how many people live in your household? * 1 2 3 4 5 6 7 8 More than 8

Of these, how many are under 18 years of age? * 0 1 2 3 4 5 6 7 8 More than 8

Of these, how many are over 60 years old? * 0 1 2 3 4 5 6 7 8 More than 8

Either someone in my household or myself identifies as: disabled, a survivor of domestic violence, stalking, sexual assault, and/or recovering from substance abuse. * YesNo

Did you serve, or are you currently serving, in the United States Armed Forces? (Army, Marine Corps, Navy, Air Force, Space Force, Coast Guard, Reserve or National Guard) * YesNo

What is the gross annual income (before taxes and deductions) for your household? Do not use $ sign. *

The following questions are optional and are collected for reporting and equity purposes only. They will not affect your eligibility. Do you speak English? YesNo

What is your primary language?

Race/Ethnicity (select all that apply) American Indian or Alaska NativeAsianBlack or African AmericanHispanic, Latino, or Spanish OriginMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderWhiteOtherPrefer not to answer

Gender MaleFemaleOtherPrefer not to answer

Immigration background: I was born in the United StatesI moved to the U.S. from another countryPrefer not to answer

Please share your country of origin:

Comments