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Bloomington Housing Rehabilitation Program Pre-Application Form

Thanks for your interest in the City of Bloomington's Housing Rehabilitation Programs. Please answer all questions to the best of your knowledge. The submitted information will be verified at the time of application. Incomplete forms may be rejected for the lack of This form is the first step in the process. After you submit it, staff will review it to see which program you might be eligible to apply. A link to the full program application will be emailed if you meet our basic criteria. The full application will determine program eligibility. If you are interested in the IHDA-Home Repair and Accessibility Program, you may be placed on a waitlist.

Home Phone Number

Work Phone Number

Does the household have Limited English Proficiency?

Yes

Preferred language:

Total Household Annual Gross Income (Before taxes and deductions)

Type of income (salary, retirement, social security, etc.)

List all those living in the household and their birth dates

Do you have a mortgage on this property?

Yes

Are you current with your mortgage payment

Yes

Current total monthly housing payment (Mortgage Payment, Taxes, Insurance, HOA)

Do you have any other liens on the property?

Yes

If yes, list the types of liens (mechanic's lien, home equity loan, home equity line of credit):

Does your property have any tax liens?

Yes

Is this property your sole residence?

Yes

List the work that needs to be done

How did you hear about the program?

Is there a particular program you are interested in?

I certify that the information provided above is true, complete, and accurate to the best of my knowledge. I understand that providing false representations herein may constitute an act of fraud. I acknowledge that the information provided is being used for the specific purpose of determining whether my household is eligible to receive assistance through the City of Bloomington Housing Rehabilitation grant. I will fully cooperate to obtain or provide any necessary documents to confirm the information provided.

Yes

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

A member of the grants management division will follow up with you shortly to discuss possible housing rehabilitation programs.

Bloomington Housing Rehabilitation Program Pre-Application Form

Head of Household

Address