Accessibility Grant Inquiry

For low-income persons with physical disabilities to improve access and safety. (Some renters may not be eligible.)

Please review the income chart below. To be eligible for the program, the current annual gross income for all household members 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.

Current Annual Gross Income Limits
Household Size 1 2 3 4 5 6 7 8
Annual Income 49,250 56,250 63,300 70,300 75,950 81,550 87,200 92,800

1. Do you live in Clackamas County?
Yes No

Name

Property Address

City

State

Zip Code 97045 / 97045-1234

Mailing Address

City

State

Zip Code 97045 / 97045-1234

Phone ###-###-####

E-mail name@example.com

2. Do you currently live in the home that you want to make handicap accessibility improvements to?
Yes No

3. How many people live in your house?

4. Do you have tenants who live in the home with you?
Yes No

5. What is the total current monthly gross income for ALL persons living in the home?

6. Please indicate all the sources of income for your household. 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
Annuities
Insurance policies
Retirement funds
Disability benefits
Unemployment benefits
Disability compensation or workers compensation
Welfare assistance, such as TANF (Food Stamps do not count)
Alimony
Child support
Any other regular contribution or gift
Other (list source)

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

8. Do you own or rent the property?
Own Rent

9. If you rent, will your landlord agree to the modifications?
Yes No

10. Type of dwelling?
House Duplex Manufactured home on land Manufactured home in park

11. What year was the house built?

12. Please tell us how you heard about the program. Check ALL that apply

County web site
County or city newsletter
Brochure
Family, friend or neighbor
Other

13. What accessibility improvements are needed

14. 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.

Submitter Name

Submitter Organization

Submitter Email name@example.com

Submitter Phone ###-###-####

Submitter Relationship/Connection to applicant

15. Comments

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