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2. 
4. Applicant Information
6. Homeowner's First Name*
7. Homeowner's Last Name*
9. Co-owner's First Name (if applicable)
10. Co-Owner's Last Name (if applicable)
12. Address*
14. Address Continued
16. City*
17. State*
18. Zip*
20. Neighborhood*
22. Phone Number*
23. Alternate Number*
25. Homeowner's Age(s)*
26. Email Address*
28. U.S. Citizen or Permanent Resident? *
    -- Select One --YesNo
32. Homeowner's Insurance? *
    -- Select One --YesNo
33. Property Taxes Paid? *
    -- Select One --YesNo
34. Current on Mortgage? *
    -- Select One --YesNo
36. Do you live in this home as your primary residence? *
    -- Select One --YesNo
38. How many years have you owned and occupied this home? *
40. Are there any children under 6 living in the home? *
    -- Select One --YesNo
42. Are there any individuals with mobility impairments living in the home? *
    -- Select One --YesNo
44. Are your utilities current and operating? *
    -- Select One --YesNo
46. Do you own more than this one property? *
    -- Select One --YesNo
48. Is the property for sale or intended to be sold within 12 months? *
    -- Select One --YesNo
50. Previously received rehab assistance on this property in the last 15 years? *
    -- Select One --YesNo
52. Is this a detached single-family home? *
    -- Select One --YesNo
53. If no, please describe:
57. Income Sources - Check ALL that apply*

    1. Wages
    2. Social Security
    3. Disability
    4. Pension
    5. Rental Income
    6. Unemployment
    7. Child Support
    8. Other
59. Total Annual Income of ALL people in home: *
60. Number of People in Household? *
64. DOES THIS HOUSE HAVE?
66. Hot and cold running water? *
    -- Select One --YesNo
67. Brief description of repair/issue
69. A bathtub or shower? *
    -- Select One --YesNo
70. Brief description of repair/issue
72. A sink with a faucet? *
    -- Select One --YesNo
73. Brief description of repair/issue
75. A stove or a range? *
    -- Select One --YesNo
76. Brief description of the repair/issue
78. A refrigerator? *
    -- Select One --YesNo
79. Brief description of the repair/issue
81. A working toilet?*
    -- Select One --YesNo
82. Brief description of repair/issue
86. REPAIRS NEEDED?
88. Electrical*
    -- Select One --YesNo
89. Brief description of the repair/issue
91. Plumbing*
    -- Select One --YesNo
92. Brief description of the repair/issue
94. AC/Heating*
    -- Select One --YesNo
95. Brief description of the repair/issue
97. Siding Repair*
    -- Select One --YesNo
98. Brief description of the repair/issue
100. Exterior Doors*
     -- Select One --YesNo
101. Brief description of the repair/issue
103. Windows*
     -- Select One --YesNo
104. Brief description of the repair/issue
106. Roof/Gutters*
     -- Select One --YesNo
107. Brief description of the repair/issue
109. Exterior Painting*
     -- Select One --YesNo
110. Brief description of the repair/issue
112. Interior Painting*
     -- Select One --YesNo
113. Brief description of the repair/issue
115. Floor Repairs*
     -- Select One --YesNo
116. Brief description of the repair/issue
118. Grab Bars/Railings*
     -- Select One --YesNo
119. Brief description of the repair/issue
121. Other*
     -- Select One --YesNo
122. Brief description of the repair/issue

126. Review for Waitlist:

     Prospective applicants who meet the baseline criteria are added to the waitlist. Prospective applicants who do not meet the baseline criteria will not be considered further and will be notified by mail and/or email of the reason for ineligibility and appeal process.  

     Prioritization 

     Waitlisted prospective applicants who qualify for Renovate Norfolk will be prioritized according to need. 

     Waitlisted prospective applicants who qualify for Strengthening Neighborhoods OOR will be prioritized based on location within targeted blocks and zones.   

     Lottery Process

     RVN staff will only send out the number of applications that funding capacity and contractor availability allows. Randomized selection will occur by assigning prospective applicants within each priority tier a unique identifier and utilizing a random number selection process.  

     CERTIFICATION

     I understand that completing this survey is not an application for funding or a guarantee of funding. I understand participation in this program is completely voluntary and that I must complete this survey to be added to the waiting list. I understand that selection to complete a full application will be based on meeting the baseline criteria and the prioritization process documented above.

128. Electronic Signature*
129. Date*
     Date
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131. 1. Receive an email copy of this form.
132. Email address

     This field is not part of the form submission.

133. Submit

* indicates a required field