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2. Please complete entirely. Our programs are limited to Butler County, Pennsylvania residents only. 

4. Head of Household Name*
5. Email Address*
7. Street Address*
9. City*
10. Township / Borough *
11. Zip Code*
12. Phone Number*
14. Head of Household Date of Birth*
    Head of Household Date of Birth
15. Head of Household Gender*
16. Race / Ethnicity*
20. Number of Adults*
21. Number of Children
22. TOTAL Household Income*
24. Mortgage Status*
    -- Select One --Property is not mortgaged.Property is mortgaged & CURRENT.Property is mortgaged & PAST DUE
25. Home Type*
    -- Select One --Traditional BuildManufactured or Mobile
27. Approximate Age of Home*
28. Insurance *
    -- Select One --Insurance is CURRENT.Insurance is PASTDUE. I/We do not have homeowners insurance.
29. Taxes*
    -- Select One --Taxes are CURRENT.Taxes are PASTDUE.
31. Have you participated in any other grant funded rehabilitation program? If yes, please provide the date.
33. Notes
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field