Home Access Grant

Please review the income chart below. To be eligible for the program, the current gross income for all household members over the age of 15 must be below the limit for the size of the household. If you think you are income-eligible, complete and submit this form.We will review it and, if you appear to meet the basic criteria, we will send you an application.

Household Size	1	2	3	4	5	6	7	8
Annual Income	38,850	44,400	49,950	55,500	59,950	64,400	68,850	73,300
Monthly Income	3,238	3,700	4,163	4,625	4,996	5,367	5,738	6,108

Name

Address

City

ZIP Code

Phone

1. Do you live in Clackamas County?
Yes No

2. Do you currently live in the home that you want to repair?
Yes No

3. How many people live in your house?

4. What is the total current monthly gross income for ALL persons living in the home over age 15?

5. Please indicate the sources of your income. Check ALL that apply:
Earned Income (salaries, wages, commissions, tips, bonuses, etc.)
Business income
Interest or dividends
Income from real estate or personal property (e.g. rental income)
Social Security
Annuities
Insurance policies
Retirement funds
Disability or death benefits
Unemployment benefits
Disability compensation or workers compensation
Welfare assistance, such as TANF (Food Stamps do not count)
Alimony
Child support
Any other regular contribution or gift
Other

6. Do you file federal income tax returns?
Yes No

7. Do you own or rent the property?
Own Rent

8. If you rent, will your landlord agree to the modifications?
Yes No Not Applicable

9. Type of dwelling?
House Duplex Manufactured home on land Manufactured home in park

10. What year was the house built?

11. Would you like your application packet e-mailed or mailed?
Email US Postal Mail

12. Please tell us how you heard about the program. Check ALL that apply:
County web site
County or city newsletter
Brochure
Family, friend or neighbor
Other

13. What accessibility improvements are needed:

Someone else
If this inquiry was completed by someone other than the applicant, please provide your name, email address or phone number and indicate your connection to the applicant

Name:

Organization:

Email Address:

Phone number:

Relationship/Connection to applicant:

14. Comments:

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