Revision Date: 3/10/2016
A Community Asset!
P. O. Box 1830
Lower Lake, CA 95457
Tel 707 994-1100
Lake County Repair and Rebuild Fire Relief Intake Application:
This is not a promise of services. Intake application is for information only. Further documentation will be requested to
determine eligibility for services. Selection is not automatic; all complete applications will be reviewed and considered by
Habitat for Humanity Lake County administration.
Date: Client Name:
Current Contact Mailing Address:
Contact Phone # Contact email:
Address where you are living now
Describe living conditions where you are now:
Temporary or Permanent?
Have you registered with FEMA: Yes: No: If yes, please provide FEMA Case #
Registered with the Red Cross: Yes: No: If yes, please provide Red Cross Case #:
Are you a Veteran: Yes: No:
Are you a legal U.S. resident? Yes: No: Can you provide proof of legal status? Yes: No:
Address of Property Loss:
Own: Rent: (ownership/rental status will be verified)
Was this property your primary residence: Yes: No:
How long did you live at this address before the fire:
Do you own the land upon which the home stood: Yes: No:
Do you have a mortgage/loan on the property? How much is unpaid on loan?
Can the structure be repaired: Yes: No:
If yes, please describe damage:
How long did you own your home: Do you want to rebuild? Donate Land?
Would you be willing to relocate within Lake County? Yes: No:
Will you consider a manufactured home?
Was your home insured? Yes: No: Amount of settlement:
Number of individuals living in the home: How many children?
Gross Annual Household Income of all family members over 18: (will be verified)
