Interest Form

Please review the Apply for a Home web page before submitting this form . Please note that this Interest Form is NOT an application for a Habitat home, but provides us with your contact information so that we can send you more information. Please allow up to 4 weeks for information to be provided to you.

YOUR INFORMATION *First Name:
*Last Name:
*Address:
*City:
*State:
*Zip:
Email Address:

Would you like to subscribe to our email list?

No thanks.

Yes, please subscribe me.

*Home Phone:
Cell Phone:
Work Phone:
*When is a good time to call you?
*Which number?

LIVING SITUATION *Have you been living in La Plata County for the past year?

*Have you been working in La Plata County for the past year?

*How many people would be living in the Habitat house, including you?

*Are you applying alone?
If no, name of other person:
Relationship to you:

INCOME *What is your income? : [ per hour ]
*How many hours per week?
How much Annually? (including any child support and government assistance recieved):

If someone else is applying with you What is their income? [ per hour ]
How many hours per week?
Have you had a steady income for the last 12 months?

How much Annually? (including any child support and government assistance recieved):

*Have you had a steady income for the last 12 months?

*Why are you interested in the Habitat Homeownership Program: