Fillable City of Shreveport Department of Community Development EMERGENCY (City of Shreveport)

Fill Online, Printable, Fillable, Blank City of Shreveport Department of Community Development EMERGENCY (City of Shreveport) Form

Use Fill to complete blank online CITY OF SHREVEPORT (LA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

City of Shreveport Department of Community Development EMERGENCY (City of Shreveport)

On average this form takes 22 minutes to complete

The City of Shreveport Department of Community Development EMERGENCY (City of Shreveport) form is 2 pages long and contains:

  • 0 signatures
  • 15 check-boxes
  • 80 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Shreveport

BROWSE CITY OF SHREVEPORT (LA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
City of Shreveport
Department of Community Development
EMERGENCY REPAIR REQUEST FOR SERVICE
HOUSEHOLD DATA
Name:
Address:
Phone Number: E-mail Address:
Marital Status: Female Head of Household? □ Yes □ No
How long have you lived at this address: Do you own other real estate property? □ Yes □ No
If “Yes” please list address:
Have you previously received services from the City of Shreveport for home repairs? □ Yes □ No
Do you consider yourself to be Hispanic? □ Yes □ No
Please check one of the following which applies to you:
□ American Indian/Alaskan Native □ American Indian/Alaskan Native & Black
□ American Indian/Alaskan Native & White □ Asian
□ Asian & White □ Black/African American
□ Black/African American & White □ Native Hawaiian/Pacific Islander
□ Other □ White
Race/Ethnicity:
Priority 1 – Emergency Repairs
An emergency is a situation or condition that occurred recently without warning, and is considered
detrimental or one that poses a threat to life and/or the health and safety of occupants and requires immediate
action. Emergency Repairs are limited to the following:
Please check all that apply to your situation.
□ Sewer line breaks (visible raw sewage) or no connection
□ Fresh water line breaks (visible water leak)
□ Gas line break/leaks
□ Water heaters (inoperable or unsafe units)
□ Unsafe or inoperable heating systems
LIST ALL PERSONS LIVING IN HOUSEHOLD:
First Name
Last Name
Relationship
Age
Sex
Social Security #
SOURCE OF INCOME: WHAT ARE THE SOURCES OF YOUR INCOME?
Family Member
Employer or
Income Source
Address of Employer
Telephone
Number
Monthly
Income
Additional Income
& Source
CONSENT TO RELEASE INFORMATION
Signing below authorizes the release of information from your records to the City of Shreveport, Department of Community
Development’s Neighborhood Revitalization Program. This authorization is made in connection with an application that has been
made in order to obtain CDBG funds for home repair.
This release is specific to all organizations including FEMA.
Initials ________________________
APPLICANT CERTIFICATION
The applicant (whether one or more) certifies that all information in the application and all information furnished in support of this
application, is given for the purpose of obtaining a Housing Rehabilitation grant from the City of Shreveport, Department of Community
Development’s Neighborhood Revitalization Program, and is true and complete to the best of the applicant's knowledge and belief. The
applicant additionally certifies that the applicant is the OWNER AND OCCUPANT of the property to be repaired. The applicant consents
to the verification of any of the information contained in this application.
I understand that the release of information does not guarantee that assistance will be provided, but without the information, assistance
may not be available.
Initials ________________________
Signature of Applicant(s)
Applicant’s Signature:
Date:
Applicant’s Signature:
Date:
PENALTY FOR FALSE OR FRADULENT STATEMENT: U.S.C. Title 18, Section 1001, provides:
“Whoever, in any matter within the jurisdiction of any department or agency of the United States, knowingly
and willfully falsifies…or makes any false writing or document knowing the same to contain any false,
fictitious, or fraudulent statement or entry shall be fined not more than $10,000 or imprisoned not more than
five years, or both.”
If additional persons reside in your household, please list on separate page.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

City of Shreveport Department of Community Development EMERGENCY (City of Shreveport)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document