Homeowner Intake

Healthy Housing Owner Intake

There may be a waiting list to receive assistance. All information provided is confidential and must be retained by the Healthy Housing program. If you or someone in your family has a disability and you believe you might require special assistance, you are welcome to request this help at any time. If you are in need of an interpreter, we will arrange for one to assist you. If your home was built pre-1978 and has a child under the age of 6, a lead inspection risk assessment will need to be completed. All homes enrolled in this program will be tested for radon gas.

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Today's Date

Property Owner Information (Please fill out this section to the best of your knowledge.)

Name*

First Last

Address*

Street Address City State ZIP Code

County*

Race/Ethnicity

Insurance type

Contact Information

Home Phone*

Cell Phone*

Preferred Language*

Co-Applicant Name

First Last

Phone

How Can We Reach You?

We are so excited about your interest in the Healthy Housing Program. Please let us know how best to contact you.

Best Time to Contact You*

Preferred Methods of Contact*

Phone call

Text

Your Email Address*

Your Phone*

Text Number*

HOUSEHOLD MEMBERS & INCOME

Please list all household members who are living at this address. Please list all household income for adults over 18 who are not full time students. NOTE: Do NOT click the "+" sign.

1- Head of Household*

Date of Birth*

Respiratory Conditions*

None

Asthma

Allergies

COPD

Emphysema

Lung Cancer

Mesothelioma

Other respiratory conditions

1- Please enter your annual income

2- Household Member

Date of Birth

Respiratory Conditions

None

Asthma

Allergies

COPD

Emphysema

Lung Cancer

Mesothelioma

Other respiratory conditions

2- Please enter your annual income

3- Household Member

Date of Birth

Respiratory Conditions

None

Asthma

Allergies

COPD

Emphysema

Lung Cancer

Mesothelioma

Other respiratory conditions

3- Please enter your annual income

4- Household Member

Date of Birth

Respiratory Conditions

None

Asthma

Allergies

COPD

Emphysema

Lung Cancer

Mesothelioma

Other respiratory conditions

4- Please enter your annual income

5- Household Member

Date of Birth

Respiratory Conditions

None

Asthma

Allergies

COPD

Emphysema

Lung Cancer

Mesothelioma

Other respiratory conditions

5- Please enter your annual income

6- Household Member

Date of Birth

Respiratory Conditions

None

Asthma

Allergies

COPD

Emphysema

Lung Cancer

Mesothelioma

Other respiratory conditions

6- Please enter your annual income

7- Household Member

Date of Birth

Respiratory Conditions

None

Asthma

Allergies

COPD

Emphysema

Lung Cancer

Mesothelioma

Other respiratory conditions

7- Please enter your annual income

8- Household Member

Date of Birth

Respiratory Conditions

None

Asthma

Allergies

COPD

Emphysema

Lung Cancer

Mesothelioma

Other respiratory conditions

8- Please enter your annual income

Property Information

Type of Property*

Please select the type of property.

If it's a multi-family unit, how many units are there?

Please select the year house was built, if known.*

How did you hear about us or what agency referred you?*

Why are you applying to Healthy Housing Omaha?*

Section 8 Housing*

Yes

Housing Authority*

INDEMNIFICATION. The Client agrees to indemnify, defend, and hold harmless Healthy Housing Omaha, including its board of directors, officers, employees, agents, and affiliates (collectively, the "Indemnified Parties"), from and against any and all claims, liabilities, damages, losses, costs, expenses (including reasonable attorneys' fees), judgments, fines, and penalties arising out of or related to the Client's use of Healthy Housing Omaha's services. This indemnity covers, but is not limited to, any damages or liability arising from the Client's breach of this Agreement, negligence, willful misconduct, or any other action by the Client that results in harm or liability. The Indemnified Parties shall not be liable for any indirect, special, incidental, consequential, or punitive damages, including lost profits, arising out of or in connection with this Agreement or the services provided hereunder. The Client's obligation to indemnify the Indemnified Parties shall survive the termination or expiration of this Agreement."

Signatures- By typing in your name, today's date, and clicking "Submit", you agree that all the information is true to the best of your knowledge. I understand that completing the application process is no guarantee of receiving funding.

Signature*

Date*

Are you filling this form out on behalf of someone other than yourself?*

Yes

Name of individual completing application on behalf of applicant.*

First Last

Job Title*

Organization*

Org. Phone*

Name of Applicant*

First Last

Is there a co-applicant?*

Yes

Name of Co-Applicant*

First Last

Name

This field is for validation purposes and should be left unchanged.

Healthy Housing Owner Intake

Expert Form Tip: Sync with an Email Add-On

Property Owner Information (Please fill out this section to the best of your knowledge.)

Contact Information

How Can We Reach You?

HOUSEHOLD MEMBERS & INCOME

Property Information

Signatures- By typing in your name, today's date, and clicking "Submit", you agree that all the information is true to the best of your knowledge. I understand that completing the application process is no guarantee of receiving funding.

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