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CTP URP CDBG‐ERP CHS Weatherization OTHER
FOR CITY OF HIGH POINT USE ONLY:
Revision Date: June 2019
High Point Housing Rehabilitation Assistance Program –
Eligibility Screening Form
(Please note that this is NOT an application. You will be contacted regarding your eligibility. Thank you!)
Date: Do you or any of your relatives work for the City?
If so, who?
Which department?
Name of Applicant: First Middle Last
Name of Co-Applicant: First Middle Last
Mailing Address of Applicant: City State Zip
Phone Numbers: Home Work Cell
Email:
Contact Person (if different from Applicant): Phone:
Is the property address different from the mailing address of the applicant: Yes No
Property Address (if different): City
State Zip
List items in the home that need rehabilitation/adding (e.g., roof, windows, plumbing, handicap ramp, etc.):
Was the property built prior to 1978? Yes No
How many people live in the home? How many children under age 18? Ages
At least one member of the household is: Aged 62 or older Handicapped/Disabled Household Size 5+
Single-Parent Household Veteran – not dishonorably discharged
Do you have any children with an elevated blood lead level (<10µg/dl)? Yes No
What is your annual household income? $
Maximum Income Per Category (HUD) – 2019*
1
2
3
4
5
6
7
8
30% AMI $12,900 $14,750 $16,600 $18,400 $19,900 $21,350 $22,850 $24,300
50% AMI $21,500 $24,550 $27,600 $30,650 $33,150 $35,600 $38,050 $40,500
80% AMI $34,350 $39,250 $44,150 $49,050 $53,000 $56,900 $60,850 $64,750
Have you received assistance through any of our programs before?
How did you hear about our progr
am?
PLEASE RETURN FORM TO: City of High Point, CD&H, P. O. Box 230, High Point, NC 27261 OR 336‐883‐3355 (Fax)
