Christmas in Action - Home Repair Application

Homeowner’s Name *

Homeowner’s Address *

Phone Number *

Other Family Contacts

Requested Repairs *

Please describe the repairs needed.

Homeowner Type *

Elderly

Disabled

Veteran

Limitations

Describe any physical limitations.

Veteran Status

Yes

Years of Service

DD214 Attachment

Click to choose a file or drag here

Size limit: 25MB per file

Please upload DD214 for proof of service.

Home Ownership Status *

Yes

Do you own the home?

Home Tax Status *

Yes

Is the home tax paid?

Home Insurance Details *

Referrer’s Name *

Referrer’s Email *

Date of Referral *

Applicant’s Awareness *

Yes

Is the applicant aware of this referral?

Proof of Income

Click to choose a file or drag here

Size limit: 25MB per file

Upload proof of income.

Agreement and Consent *

Yes

Do you agree to allow the House Selection Chairman to contact you?

Johnson County Acknowledgement *

Please acknowledge that this application is only for addresses within Johnson County, Texas.

Permission for Sharing and Photos *

Yes

Do you agree to share your form responses and give permission for photos to be used in brochures and news articles?