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

  • Section A
  • Section B
  • Section C
  • Section D
  • Section E

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.

Full Name

Date

How did you Hear About GHP?

Referred by (name)