Request a Home Repair

Contact Information

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip Code: *

Phone Number: *

E-Mail:

About you:

Sex: *

Female Male

Date of Birth: *

Do you have a permanent disability? If so, specify:

Total annual household income (Include all sources of income from ALL residents) : *

Is your home within the city of Portland? *

Yes No

Do you own and reside at the address on the application? *

Yes No

Does anyone else share the deed of the home? *

Yes No

For each person who shares the deed of the home, state the following:

Name
Age
Relationship to you
Able to help with repairs (yes/no)

For each person who resides on the property, state the following:

Name
Age
Relationship to you
Able to help with repairs (yes/no)

Please check all racial and ethnic categories that apply to you: *

White:

Black / African-American:

Asian:

American Indian / Alaskan Native:

Native Hawaiian / Other Pacific Islander:

American Indian / Alaskan Native & White:

Asian & White:

Black / African American & White:

American Indian / Alaskan Native & Black / African American:

Other:

Are you Hispanic? *

Yes No

What types of repairs would you like to request?
Check all that apply:

Carpentry:

Electrical:

Plumbing:

Safety aids (smoke detectors, grab bars, etc.):

Roof patches:

City citation:

Other:

Comments / Questions

Fields marked with * are required.

REACH Community Development

Request a Home Repair

Community Home Repair