Home Repair Loan Inquiry

For low-income homeowners

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


Property Address



Zip Code 97045 / 97045-1234

Mailing Address



Zip Code 97045 / 97045-1234

Phone ###-###-####

E-mail name@example.com

2. Do you currently live in the home that you want to repair?
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
Insurance policies
Retirement funds
Disability 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

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

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

9. Is your property in a trust? (Properties in a trust are not eligible)
Yes No

10. Is there a Reverse Mortgage on your property?(reverse mortgages are not eligible)
Yes No

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

12. What year was the home built?

13. 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

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

15. What is the balance of your first mortgage loan?

16. Is there a second mortgage?
Yes No

If yes, balance:

17. Is there an equity line of credt?
Yes No

If yes, credit limit:

18. Are the payments current on all your mortgage loans?
Yes No

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

If yes, amount and who.

20. Are you considering refinancing?(if yes, you may want to before you obtain this loan.)
Yes No

21. Are the property taxes paid?
Yes No Deferred

Are they included in your payment?
Yes No

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

23. 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

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

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

26. 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


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