Click on the links below for Application for Assistance and see the types of incomes we accept for proof.
Application for Assistance
You may complete our on-line form below.
Please note, this form does not have the option to save and return, so you must complete the entire form and submit the form. All sections must be completed in order for the form to be submitted.
- Section A – Personal Inforamtion
- Section B – Repair Requests
- Section C – Financial Information
- Section D – Home Information
- Section E – Signatures and Certification of Accuracy
Applicant
First Name
Last Name
Date of Birth
Social Security Number
Physical Address
Line 1
Line 2
City, State, Zip
Mailing Address
Line 1
Line 2
City, State, Zip
Contact
Phone Number
Alternate Phone Number
Email Address
Alternate Contact Person
Alternate Contact Person Phone
Demographics
Gender
Race (check all that apply)
Military Status
Section B - Repair Requests
Please provide all the information requested. Where not applicable, mark the box “N/A.”
PLEASE INDICATE THE REPAIRS YOU ARE REQUESTING FOR THE PURPOSE OF REMOVING HAZARDS TO YOUR HEALTH AND SAFETY AND/OR PROVIDING EMERGENCY REPAIR. PLEASE ALSO INDICATE HOW LONG THE REPAIRS HAVE BEEN NEEDED FOR EACH ITEM LISTED BELOW:
Heating Repairs Requested
Electric Repairs Requested
Plumbing Repairs Requested
Roof Repairs Requested
Step/Porch Repairs Requested
WAS THIS HOME DAMAGED IN ANY EVENT SUCH AS A HURRICANE, TORNADO, FLOOD, ETC.? If you checked “yes” for this question, please specify the event, date of the event, and damage incurred.
WAS THE HOMEOWNER’S INSURANCE PAYMENT MADE FOR ANY ABOVE LISTED DAMAGE? If you checked yes, please provide the insurance company’s name, the payment amount received, and the damage the payment was received for.
IS THE HOMEOWNER PENDING ANY REPAIRS BY THIRD PARTY FUNDING, (I.E., INSURANCE, FEMA, ETC.)? If you checked “yes” for this question, please specify the anticipated amount to be received and specific work to be completed.
PLEASE INDICATE ANY MEDICAL CONDITIONS THAT YOU OR YOUR HOUSEHOLD MEMBERS HAVE WHICH MAY AFFECT YOUR NEED FOR THESE REPAIRS (e.g., in a wheelchair, on dialysis, has diabetes, etc.)
Section C - Financial Assistance
Please provide all the information requested. Where not applicable, mark the box “N/A.”
Employer
Average Monthly Income (after taxes)
Retirement/Pension
Government Assistance
Type of Government Assistance
Average Monthly Assistance (or N/A)
SNAP-Food Stamps
Expenses
Mortgage Expense
Average Monthly Bills
Other Expenses
Assets
Cash Assets (savings, checking, stocks, bonds)
Do You Own Other Property
Location of Other Property (or n/a)
Section D - Home Information
Please provide all the information requested. Where not applicable, mark the box “N/A.”
Name of Homeowner
First Name
Last Name
Proof of Ownership Provided
Home Information
Type of Home (trailer, etc)
Year Built
Date Purchased
Years Living in the Home
People Living in the Home
List all persons residing in the home and income provided by each resident. Note: failure to report another resident and/or household income may disqualify you from receiving assistance from ghp. For each person, list - Full Name, Relationship, Age, Monthly Income and Source
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Section E - Signatures and Certification of Accuracy
I certify, under the penalty of perjury under the laws of the Commonwealth of Virginia that all statements, answers, and representations made in this application, including all supplementary statements attached hereto, are true and correct, and that I have reviewed the entire contents of this application. I further understand that to qualify for a home repair I must provide GHP proof of my monthly income and proof of ownership of my home. I further authorize GHP to photograph my home, myself, and my property in connection with repairs, and that GHP may use such photographs of my home, myself, and my property for any lawful purpose, including but not limited to such purposes as publicity, illustration, advertising, social media, and web content. By signing below, I also give the Gloucester Department of Social Services and GHP permission to share information about my home and living conditions for the purpose of repairing my home.