Housing Rehabilitation Loan Inquiry

Please review the income chart below. To be eligible for the program, the current gross income for all household members over the age of 15 must be below the limit for the size of the household. If you think you are income-eligible, complete and submit this form.We will review it and, if you appear to meet the basic criteria, we will send you an application.

Household Size12345678
Annual Income38,85044,40049,95055,50059,95064,40068,85073,200
Monthly Income3,2383,7004,1634,6254,9965,3675,7386,108





Zip Code 97045 / 97045-1234

Phone ###-###-####


1. Do you live in Clackamas County?
Yes No

2. Do you currently live in the home that you want to repair?
Yes No

3. How many people live in your house?

4. What is the total current monthly gross income for ALL persons living in the home over age 18?

5. Please indicate the sources of your income. Check ALL that apply
Earned Income (salaries, wages, commissions, tips, bonuses, etc.)
Business income
Interest or dividends
Income from real estate or personal property (e.g. rental income)
Social Security
Insurance policies
Retirement funds
Disability or death benefits
Unemployment benefits
Disability compensation or workers compensation
Welfare assistance, such as TANF (Food Stamps do not count)
Child support
Any other regular contribution or gift

6. Do you file federal income tax returns?
Yes No

7. Whose name(s) appear on the title to the property?

8. Type of dwelling?
(Manufactured homes in parks do not qualify for the Housing Rehab Loan Program.)
House Duplex Manufactured home on land

9. What year was the house built?

10. How are you purchasing the property?
Mortgage Contract N/A - Own free and clear

If you are purchasing on a contract, is the seller willing to sign a consent to lien?
Yes No Not Applicable

11. What is the total County assessed Real Market Value?

12. What is the balance of the loan?

13. Is there a second mortgage or line of credit?
Yes No

If yes, amount and source:

14. Are there any other liens against your property?
Yes No

If yes, amount and who:

15. Are the property taxes paid?
Yes No Deferred

16. Do you have homeowners insurance on this home?
Yes No

17. Check all areas in your home that need repair
Gutters / Downspouts
Furnace / Heat System
Exterior Stairs / Porches
Water System
Insulation / Weatherization
Septic / Sewer
Exterior Paint
Interior Paint

18. Check every statement that describes your home's current condition
There is no working heat source
There is no working water system
The roof is actively leaking
There is no working septic /sewer

19. Please tell us how you heard about the program. Check ALL that apply
County web site
County or city newsletter
Family, friend or neighbor

20. This inquiry was completed by
Potential applicant Someone else

If this inquiry was completed by someone other than the applicant, please provide your name, email address or phone number and indicate your connection to the applicant.




Phone ###-###-####

Relationship/Connection to applicant