Prequalification Survey for Home Modification Tax Credit Program
Applicant Information
*
Applicant First Name
*
Applicant Last Name
*
Phone
*
Email
Primary Contact
--None--
Applicant
Representative
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.
Representative First Name
Representative Last Name
Representative Phone
Representative Email
Project Address
*
Physical Street Address
Lot or Unit
*
City
*
State
*
Zip Code
County
--None--
Adams
Alamosa
Arapahoe
Archuleta
Baca
Bent
Boulder
Broomfield
Chaffee
Cheyenne
Clear Creek
Conejos
Costilla
Crowley
Custer
Delta
Denver
Dolores
Douglas
Eagle
Elbert
El Paso
Fremont
Garfield
Gilpin
Grand
Gunnison
Hinsdale
Huerfano
Jackson
Jefferson
Kiowa
Kit Carson
Lake
La Plata
Larimer
Las Animas
Lincoln
Logan
Mesa
Mineral
Moffat
Montezuma
Montrose
Morgan
Otero
Ouray
Park
Phillips
Pitkin
Prowers
Pueblo
Rio Blanco
Rio Grande
Routt
Saguache
San Juan
San Miguel
Sedgwick
Summit
Teller
Washington
Weld
Yuma
Copy Physical Address to Mailing Address
Mailing Address
Mailing Lot or Unit
Mailing City
Mailing State
Mailing Zip Code
Other Information
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?