City of Brunswick, GA

HOMEOWNER REHABILITATION AND RECONSTRUCTION PROGRAM (HRRP)

General Instructions

Completing this survey is the first step in the application process.
Please provide as much information as possible.
Once you have submitted your survey, a case manager will review your responses and call you to discuss your next steps.
For help, please call us at 912-280-1999.

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* TO BE COMPLETED BY APPLICANT:

Last Name, First Name, and Middle

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* Enter Current Address (Not Damaged Property Address)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* Date of Birth (MM/DD/YYYY)

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* Gender

Male

Female

Prefer not to answer

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* CO-APPLICANT Information: (If Applicable)

Relationship to Applicant

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* Last Name, First Name, and Middle

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* Date of Birth (MM/DD/YYYY)

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* Gender

Male

Female

Prefer not to answer

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* ALTERNATE CONTACTS INFORMATION:
This information is being collected to assist us in locating you if you move or are living temporarily in another location. You may also list a contact who is helping you through this process.

Contact Name (first):

Contact Phone No.:

Address:

Contact Name (second):

Address:

Contact Phone No.:

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* RACE & ETHNICITY FOR THE APPLICANT (Check one):
This information is being collected to ensure compliance with the Federal Fair Housing and Equal Opportunity regulations.

White

Black or African American

Asian

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Hispanic

Non-Hispanic

Other

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* ELIGIBILITY INFORMATION:

Was your home damaged by Hurricane Irma?

Yes

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* At the time of the disaster, were you the owner of this residence?

Yes

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* Are you the current owner of the residence?

Yes

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* Program Eligibility Priorities:

What is your yearly Income?

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* Are you or a member of your household 62 years of age or older?

Yes

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* Do you or any member of your household have a disability?

Yes

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* Are there any children in the household under the age of 18?

Yes

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* PROPERTY INFORMATION:
Provide basic information concerning the damaged property (i.e. physical address of the damaged property, etc.)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

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* Do you currently have homeowner’s insurance on the Damaged Property?

Yes

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Document Check List

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* How did you find out about this program?
Please mark all that apply

Brunswick News Article

Brunswick News Ad

Brunswick News Online

96.3 iHeart Radio

103.3 iHeart Radio

Other Radio

Flier

Local Community Organization (Church, Club, Group, etc.)

Facebook or Twitter

Postcard mailing

Golden Isles Television

From a friend, neighbor, or family member, or On my Next-door neighbor

Florida Star/ Georgia Star

The Islander

The Golden Isles News & Advertiser

City of Brunswick, GA HOMEOWNER REHABILITATION AND RECONSTRUCTION PROGRAM (HRRP)

Question Title

* TO BE COMPLETED BY APPLICANT: Last Name, First Name, and Middle

Question Title

* Enter Current Address (Not Damaged Property Address)

Question Title

* Date of Birth (MM/DD/YYYY)

Question Title

* Gender

Question Title

* CO-APPLICANT Information: (If Applicable)Relationship to Applicant

Question Title

* Last Name, First Name, and Middle

Question Title

* Date of Birth (MM/DD/YYYY)

Question Title

* Gender

Question Title

* ALTERNATE CONTACTS INFORMATION: This information is being collected to assist us in locating you if you move or are living temporarily in another location. You may also list a contact who is helping you through this process.

Question Title

* RACE & ETHNICITY FOR THE APPLICANT (Check one): This information is being collected to ensure compliance with the Federal Fair Housing and Equal Opportunity regulations.

Question Title

* ELIGIBILITY INFORMATION: Was your home damaged by Hurricane Irma?

Question Title

* At the time of the disaster, were you the owner of this residence?

Question Title

* Are you the current owner of the residence?

Question Title

* Program Eligibility Priorities:What is your yearly Income?

Question Title

* Are you or a member of your household 62 years of age or older?

Question Title

* Do you or any member of your household have a disability?

Question Title

* Are there any children in the household under the age of 18?

Question Title

* PROPERTY INFORMATION:Provide basic information concerning the damaged property (i.e. physical address of the damaged property, etc.)

Question Title

* Do you currently have homeowner’s insurance on the Damaged Property?

Question Title

Document Check List

Question Title

* How did you find out about this program? Please mark all that apply

City of Brunswick, GA

HOMEOWNER REHABILITATION AND RECONSTRUCTION PROGRAM (HRRP)

* TO BE COMPLETED BY APPLICANT:

Last Name, First Name, and Middle

* CO-APPLICANT Information: (If Applicable)

Relationship to Applicant

* ALTERNATE CONTACTS INFORMATION:
This information is being collected to assist us in locating you if you move or are living temporarily in another location. You may also list a contact who is helping you through this process.

* RACE & ETHNICITY FOR THE APPLICANT (Check one):
This information is being collected to ensure compliance with the Federal Fair Housing and Equal Opportunity regulations.

* ELIGIBILITY INFORMATION:

Was your home damaged by Hurricane Irma?

* Program Eligibility Priorities:

What is your yearly Income?

* PROPERTY INFORMATION:
Provide basic information concerning the damaged property (i.e. physical address of the damaged property, etc.)

* How did you find out about this program?
Please mark all that apply