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Waitlist Pre-Application Form
Date:
(Required)
MM slash DD slash YYYY
Homeowner First Name:
(Required)
Homeowner Last Name:
(Required)
Physical address:
(Required)
City:
(Required)
State:
(Required)
New York
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Mailing address if different:
Phone number with area code:
(Required)
Email address:
(Required)
Number of people in household - Please indicate all people currently living in the home
Number of Elderly Over 62:
(Required)
Number of Elderly Over 60:
(Required)
Number of Disabled:
(Required)
Number of Veterans:
(Required)
Stick Built:
(Required)
Yes
No
Manufactured Home:
(Required)
Yes
No
Type of Home:
(Required)
Single Wide
Double Wide
1 story
2 story
Other
What year was your house built?
(Required)
Is this your Primary and Sole Residence?
(Required)
Yes
No
What type of mobility/accessibility issues do you have if any?
(Required)
What type of work needs to be done on your house?
(Required)
Town your Property Taxes are paid to:
(Required)
County:
(Required)
How did you hear about Grants available?
(Required)
Have you been a client of WCCRC in the past?
(Required)
No
Yes
Annual Household Income - select one:
(Required)
$0.00 – $10,000.00
$10,001.00 – $20,000.00
$20,001.00 – $30,000.00
$30,001.00 – $40,000.00
$40,001.00 – $50,000.00
$50,001.00 – $60,000.00
$60,001.00 – $70,000.00
$70,001.00 – $100,000.00
Comments
This field is for validation purposes and should be left unchanged.
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