Homeowner’s Name
*
Homeowner’s Address
*
Phone Number
*
Select a country
Other Family Contacts
Requested Repairs
*
Please describe the repairs needed.
Homeowner Type
*
Elderly
Disabled
Veteran
Limitations
Describe any physical limitations.
Veteran Status
Yes
No
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
No
Do you own the home?
Home Tax Status
*
Yes
No
Is the home tax paid?
Home Insurance Details
*
Referrer’s Name
*
Referrer’s Email
*
Date of Referral
*
-
Applicant’s Awareness
*
Yes
No
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
No
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
No
Do you agree to share your form responses and give permission for photos to be used in brochures and news articles?
Submit