City of Monroe Safe Housing and Healthy Homes Preliminary Application (Owner Application)

This application is used to determine your eligibility for FREE housing related testing and repairs for your home. If you have any questions or comments, please call 318-329-2256 or 318-329-2335.

* If any of the following applies to you, you may be eligible for this program:

- Own or rent a home in the City of Monroe or Ouachita Parish

- Have a child aged 6 or younger that you care for, lives in your home, or visits frequently for a minimum of 60 hours per year.

- Housing unit must be built before 1978

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* 1. Contact Information

Name *

Address *

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

Alternative Phone Number

Date of Birth *

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* 2. Is this property a vacant property?

Yes

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* 3. If the property is vacant, how long has the property been vacant?

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* 4. If the property is vacant, does the property have power, gas, and water?

Yes

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* 5. Do you own or rent your home?

Own

Rent

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* 6. Are their any additional structural add-ons to the property?

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* 7. How many people living in your household are currently 6 years or younger?

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* 8. How many children age 6 or younger frequently visit your home?

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* 9. How many people live in your household (including yourself)?

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* 10. In what year was your house built?

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* 11. Are their any additional structural add-ons to the property?

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* 12. Do you anticipate a change in the number of members in your household during the next 12 months?

Yes

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* 13. Please list below all information for each head of household member who occupies the unit.

Name (first, middle, last)

Male/Female

Race

Ethnicity (Hispanic or Non-Hispanic)

Date of Birth

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* 14. Please list below all information for each head of household member who occupies the unit.

Name (first, middle, last)

Male/Female

Race

Ethnicity (Hispanic or Non-Hispanic)

Date of Birth

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* 15. If there any additional adult members of the household please list information here.

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* 16. Will any of the above household members live anywhere except in the home?

Yes

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* 17. Will any of the household members live in the home on a less than full-time basis?

Yes

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* 18. Are you or any member of your household currently expecting a child?

Yes

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* 19. Has your house/unit ever been inspected for lead or any other hazards before?

Yes

I don't know

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* 20. If yes, when?

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* 21. Who performed the inspection and what were the findings?

Name of inspector(s)

Findings

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* 22. Has your house ever been weatherized?

Yes

I don't know

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* 23. Are you currently employed?

Yes

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* 24. If not employed, please provide additional information of household income.

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* 25. What your total household income?

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* 26. How did you hear about this program?

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* 27. Are you located in a flood zone?

Yes

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* 28. If so, have you ever experienced your home being flooded?

Yes

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* 29. If you are located in a flood zone, do you have flood insurance?

Yes

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* 30. Are you currently employed by the City of Monroe?

Yes

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* 31. Are you related to anyone working in the Planning & Urban Development Department? If yes, please list that person's name.

Yes

Other (please specify)

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* 32. Have you participated in any other program with The City of Monroe Planning and Urban Development?

Yes

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* 33. If yes, please list which program.

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* 34. I understand that the information contained in this application is being collected to determine my eligibility for this program. I authorize the owner/management agent of this property to verify all information provided on this application and my signature is consent to obtain such verification. I certify that all information and answers to the above questions are true and complete to the best of my knowledge. I consent to the release of the necessary information to determine eligibility. Please enter full legal name below.