Housing Rehabilitation Inquiry Form

In order to reach the widest possible target audience, this form should have been offered as a pdf (TEXT) file and as a web-based form on an SSL form web site and mailed via US postal mail to residents. (Download the full pdf file here)

Mayor Leonard would like residents to know that there is still funding available through the Village-wide housing rehabilitation program to assist eligible single family homeowners with needed repairs.

Applicants must own the home and meet income eligibility requirements. If you are interested in applying, please complete this inquiry form and return it to the housing manager for the Village: Shelter Planning & Development, Inc., 94 Glenwood Ave, Queensbury, NY 12804. Call 518-798-6627 with questions.

All responses are kept confidential.

Name

Address

Phone

Gross Household Income

What is the total household income for all persons over the age of 18 residing at this residence?

Under $12,500

$12,501 - 14,300

$14,301 - 16,100

$16,101 - 17,850

$17,851 - 19,300

$19,301 - 20,850

$20,851 - 23,800

$23,801 - 26,800

$26,801 - 29,750

$29,751 - 32,160

$32,161 - 35,700

$35,701 - 38,100

$38,101 - 42,850

$42,851 - 47,600

$47,601 - 51,450

Over $51,450

Household Questions

Is this a single or multi-family home?

Single Multi

Any children under the age of 5?

Yes No

Any children under the age of 5?

Yes No

Is the household female headed?

Yes No

Anyone in the household over age 62?

Yes No

Anyone in the household permanently disabled or frail elderly needing care?

Yes No

What is the average monthly cost for utilities? (Gas and electric only)

$

Heating system currently used?

Natural Gas

Oil

Propane

Wood

The most important problems to be fixed are: (Please Circle)

Electric

Plumbing

Roof

Heating

Windows

Insulation

Doors

Access

Chimney

Foundation

Lead Paint

Mold

Asbestos

Other (Identify):

Comments