Bloomington Housing Rehabilitation Program Pre-Application form

Primary Phone Number

Secondary Phone Number

Is there a preferred time to contact you?

Total Household Annual Gross Income (Before taxes and deductions)

List all those living in the household and their birth dates

List the work that needs to be done

How did you hear about the program?

Is there a particular program you are interested in?

I certify that the information provided above is true, complete, and accurate to the best of my knowledge. I understand that providing false representations herein may constitute an act of fraud. I acknowledge that the information provided is being used for the specific purpose of determining whether my household is eligible to receive assistance through the City of Bloomington Housing Rehabilitation grant. I will fully cooperate to obtain or provide any necessary documents to confirm the information provided.

Yes

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First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

A member of the grants administration team will be following up with you shortly to discuss the housing rehabilitation programs available.