Prequalification Survey for Home Modification Tax Credit Program

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Applicant Information

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Representative Information

By completing the following section, the applicant gives Division of Housing permission to contact the representative in addition to the applicant concerning the Home Modification Tax Credit Program.
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Project Address

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Other Information

Please check if the answer is yes:
Is the applicant a State Income Taxpayer?
Does this applicant have a Disability, Illness or Impairment?
Is the applicant's family income, including the income of all family members over the age of 18, less than $150,000?
Is the physical address currently occupied as the applicant’s primary residence?
Does the applicant own the home?
Has the owner agreed to the modifications?