Eligibility Form

Name*

Target Date*

Birth date*

Email*

Phone*

Property address*

Select the option that better describes your home*

Is any one pregnant in the home?

Yes

No

Are children in the home?

Yes

No

Do you have asthma or any other respiratory issues?

Yes

No

Do you own your home?

Yes

No

Are you renting?

Yes

No

Has anyone in your home had corona virus?

Yes

No

Do you receive any public assistance?

Yes

No

Are you a senior?

Yes

No

Are you a care giver?

Yes

No

Are you or a member of your family in the military/armed services?

Yes

No

Are you a member of the LGBQT+ communities?

Yes

No

Do you have a disability?

Yes

No

Are you in legal aid?

Yes

No

Are you in a HUD program?

Yes

No

Are you in any other program?

Yes

No

Do you make less than $25,000 a year?

Yes

No

Public and Indian Housing

Yes

No

Are you a Veteran

Yes

No

Are you in a housing voucher program

Yes

No

Are you unemployed

Yes

No

Are there multiple environmental issues with your unit

Yes

No

Are you a single parent

Yes

No

Are you a charity organization

Yes

No

Are you a church or house of worship

Yes

No

Paying for environmental testing would cause financial stress on my family

Yes

No

Disclaimer

Your information is strictly confidential and will never be shared with any third parties. We are committed to protecting your privacy and ensuring that all details provided are kept secure.

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