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HUD Grant Application

HUD Grant Application

HUD

Free Text

SECTION 1. GENERAL INFORMATION

What is your age?

Under 18

18-24

25-34

35-44

45-54

55-61

62 and older

2. What is your gender?

Male

Female

3. What county do you reside in?

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SECTION 2. HOUSEHOLD INFORMATION

4. What is your household size (how many people live in your house)?

5. Do you or any of your household members have a disability?

Yes

No

6. What is your housing status?

Rent

Own

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SECTION 3. FINANCIAL INFORMATION

7. What is your total annual household income (Annual, before taxes)?

Under $15,000

$15,000–$24,999

$25,000–$34,999

$35,000–$49,999

$50,000–$74,999

$75,000–$99,999

$100,000 or more

8. What is your employment status (check all that apply)?

Employed full-time

Employed part-time

Unemployed

Retired

Student

Unable to work due to disability

9. Have you received housing or financial assistance from HUD or another government agency in the past?

Yes

No

Type of assistance

Agency or program name

Year(s) received:

Amount received (approximate total)

11. Are you currently receiving any other housing assistance (local, state, or federal)?

Yes

No

If yes, please describe

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SECTION 5. ADDITIONAL INFORMATION

12. What is your primary language spoken at home?

English

Spanish

12. What is your primary language spoken at home?

13. Do you feel your current housing situation meets your household’s needs?

Yes

No

13. Do you feel your current housing situation meets your household’s needs?

14. What types of assistance or services would you find most helpful? (Check all that apply)

Rent or mortgage assistance

Utility assistance

Home repair or weatherization

Employment support

Disability accommodation

Affordable housing options

Financial education

Other

Thank you for contacting us.
We will get back to you as soon as possible.

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Southwest GA Regional Commission assures that no person shall, on the basis of race, color, national origin, age, disability, family or religious status, as provided by Title VI of the Civil Rights Act of 1964, Federal Transit Laws, 49 CFR Part 21 Unlawful Discrimination, Nondiscrimination In Federally-Assisted Programs Of The Department Of Transportation and as per written guidance under FTA Circular 4702.1B, dated October 2012, be excluded from participation in, denied the benefits of, or be otherwise subjected to discrimination or retaliation under any program or activity undertaken by the agency.

181 E. Broad Street

Camilla, Georgia 31730

Phone: 229.522.3552

Fax: 229.522.3558

Email: info@swgrc.org

EIN : 58-0940910

E-verify #52681

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