Housing Program Application Need Financial Assistance for Home Repairs? Please fill out a Housing Intake Form so we can get a sense of what you are looking for and how we can best contact you. Name of Resident(Required) First Last Address(Required) Street Address Unit # (if applicable) Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Estimated Annual Household Income(Required)Is the primary point of contact someone other than the resident of this address?(Required) Yes No Primary Point of Contact Name(Required) First Last Primary Point of Contact Phone(Required)Primary Point of Contact Email(Required) Areas of Need(Required)What sort of housing assistance are you looking for? Please select all that apply. Home Repairs Exterior Painting of Home Yard Clean Up Leaf Raking Snow Removal Bed Bug Assistance Aging in Place Assessment Installing/Checking Smoke Alarms Other Please briefly describe what you are seeking help for.Have you been cited by the City of Lakewood?(Required) Yes No Were you referred by anyone or an agency?(Required)If you were referred by someone or an agency, please let us know who below. Enter N/A if not applicable.
