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2. Name*
4. Street Address*
6. Home Phone*
7. Best Time To Call*
9. Email Address*
11. Alternate Contact*
12. Phone*
14. Relationship to the Applicant*
16. How long have you lived at the residence?*
17. Do you plan on selling your home in the next 2 years?*

    1. Yes
    2. No
18. Are you behind on your mortgage?*

    1. Yes
    2. No
20. Do you owe back taxes on the property?*

    1. Yes
    2. No
21. Is your home*

    1. Electric Only
    2. Electric and Gas
22. Are you financially able to assist in purchasing necessary supplies for repairs?*

    1. Yes
    2. No
24. You must meet one of the following criteria to receive assistance (check all the apply).*

    1. Handicapped
    2. Disabled
    3. 62 Years of Age or Older
    4. Veteran
    5. Single Head of Household with a dependent child living at home (single parent)
26. How many people currently live at the home?*
27. Of those, how many are under 18?*
29. What is your total household income?*

    This includes ALL income from ALL persons living at the property.

31. Do you have documentation to support your answers?*

    1. Yes
    2. No
32. Are you willing to provide copies of this documentation for verification?*

    1. Yes
    2. No
34. Please list any other organizations you receive assistance from (i.e Meals on Wheels, Community Enrichment Center, etc.).*
36. How did you hear about the Neighborhood Initiative Program?*
38. Please use the space below to describe what repairs you feel are necessary at your home.*
40. Please use this section to explain your current situation. What circumstances led you to need assistance with home repairs? Why should your home be considered for this program instead of another?*
42. Acknowledgment*

    By checking the box below, you understand that submission of this application does not guarantee that you will qualify for or receive assistance from the City of North Richland Hills Neighborhood Initiative Program or any of its affiliated volunteer organizations. You further understand that more documentation may be required to verify portions of this application.

    1. I Agree

44. After submitting this form you will be contacted by Neighborhood Services Staff within 7 days to discuss your application further. Each application does go through a thorough vetting process, including a site visit and a committee review.

    If you have any questions, please feel free to contact the Neighborhood Services Department at 817-427-6650 or email kjames@nrhtx.com.

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46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit Submit and Print

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