Prequalification Survey for Home Modification Tax Credit Program

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.
Representative First Name		Representative Last Name
Representative Phone		Representative Email

*Physical Street Address		Lot or Unit
*City		*State
*Zip Code		County
Copy Physical Address to Mailing Address		Mailing Address
Mailing Lot or Unit		Mailing City
Mailing State		Mailing Zip Code

Please check if the answer is yes:

Is the applicant a State Income Taxpayer?
Does the applicant or their spouse/dependent 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 $153.000.00?
Is the physical address currently occupied by the applicant and their spouse/dependent?
Does the applicant own the home?
Has the owner agreed to the modifications?