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Meals on Wheels Central Texas
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Home Repair Form
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Home Repair Form
First Name
Last Name
Phone
Email
Street Address
City
State
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Zip Code
What repairs does your home require?
Are you a home owner or renter?
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Home Owner
Renter
Home Ownership
Are you current on your mortgage?
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Yes
No
Are you current on property taxes, on a payment plan, or have a tax deferral?
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Yes
No
Does your home have a septic system?
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Yes
No
Are you an honorably discharged veteran, or the surviving spouse of an honorably discharged veteran?
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Yes
No
What is your approximate gross income per month?
Does anyone in the home have a physical or mental impairment that substantially limits one or more major life activities?
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Yes
No
Do you have any medical records documenting this impairment?
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Yes
No
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