Form Center

2. Applicant's Full Name*
3. Today's Date*
   Today's Date
5. Property Address*

   Address must be within the City limits to qualify.

7. City
8. State
9. Zip Code
11. Phone Number*
    Enter a phone number by which you can be contacted.
13. Person Completing Form

    If the person completing this form is not the homeowner, please provide your name, address, and relationship to the owner.

    Communication regarding program applications can only be made with the homeowner or authorized representative. 

14. Hurriance or storm related damage?
    -- Select One --YesNo

    Is this application related to hurricane or storm damage?

16. Do you own the property?*

    1. Yes

    1. No

    i.e., Is your name on the deed?

    NOTE- THIS PROGRAM IS NOT FOR LEASED PROPERTIES

17. Do you live in the property as your permanent place of residence?*

    1. Yes

    1. No
19. Are your property taxes current?*

    1. Yes

    1. No
20. Is there a mortgage (1st or 2nd) on the property?*

    1. Yes

    1. No
22. How many members live in the home, including yourself?*
23. Are your mortgage payments current?

    1. Yes

    1. No
25. Appraised value?*

    Enter the current appraised value of your home as you know it today

26. Is the home covered by insurance?*

    1. Yes

    1. No

    Note- Homeowner's insurance is required on the home during the lien term

28. Do you own any other properties?*

    1. Yes

    1. No

    This includes vacant land or out of state properties, solely or jointly.

30. What is the gross amount of MONTHLY income from all sources, for all household members?*

    This includes Supplemental Security Income (SSI), social security benefits, retirement pension, workers' comp, alimony, child support, unemployment benefits, and wages.

32. What is your approximate total gross ANNUAL household income? *

    This includes all sources of income from all household members before taxes or deductions.

34. Please specify which program you are applying for

    Rehabilitation Program- provides a loan up to $80,000 for homes requiring interior and exterior moderate repairs to bring them up to minimum housing standards. 

    OR

    Weatherization Program - provides a loan up to $50,000 for homes requiring exterior improvements only to make the home more energy efficient and weather resistant for Florida climate. 

36. Select Program
    -- Select One --Rehabilitation ProgramWeatherization Program

    Select the program you are most interested in.

38. Repairs Needed*

    Please explain the repairs you believe are needed for the program you have selected.  Please be advised that the program only provides repairs that make the home meet minimum Housing standards or improves its energy efficiency; it does not address cosmetic issues that do not affect the safety or welfare of the occupants.

40. Prior Assistance*

    1. Yes

    1. No

    Have you ever received or requested assistance from the City before?

41. Have any additions or alterations been made to your home that are not original to the home?*

    1. Yes

    1. No
43. Are there any special notes or circumstances that you would like for us know about with regard to your request?
45. Email Address*

    Please provide us your email address for confirmation purposes. This email will be used to communicate with you regarding your application.

    Do not provide an email address that does not belong to the applicant.  Communications can only be made directly with the applicant(s).

47. Do all owners listed on the deed reside at the residence?*

    1. Yes

    1. No
48. Are there any household members that are considered a special needs person or are disabled and receiving Supplemental Security Income (SSI) or Social Security (SS) disability?*

    1. Yes

    1. No
50. Have you received notice of foreclosure on your property?*

    1. Yes

    1. No
51. Are you aware of any outstanding liens on your property other than your mortgages?*

    1. Yes

    1. No

    (e.g. Internal Revenue Services (IRS), City, County, Code Enforcement fines, etc.)
53. Do you have any outstanding citations issued by the code enforcement department?*

    1. Yes

    1. No
54. Are you and any co-applicant US citizens?*

    1. Yes

    1. No
Leave This Blank:


56. 1. Receive an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit Submit and Print

* indicates a required field