Home Preservation - Program Inquiry

First Name

Last Name

Date of Birth

Phone Number

Cell Phone Number

Email Address

Street

City

State

Zipcode

County

You have selected Polk County, Iowa. Greater Des Moines Habitat for Humanity only serves Polk, Dallas, and Jasper counties in central Iowa. Please click, "Yes" the check box to confirm that you are interested in continuing.

You have selected Jasper County, Iowa. Greater Des Moines Habitat for Humanity only serves Polk, Dallas, and Jasper counties in central Iowa. Please click, "Yes" the check box to confirm that you are interested in continuing.

You have selected Dallas County, Iowa. Greater Des Moines Habitat for Humanity only serves Polk, Dallas, and Jasper counties in central Iowa. Please click, "Yes" the check box to confirm that you are interested in continuing. If you live in the Dallas, Texas area, please call (214) 678-2300 or visit their website Dallashabitat.org.

Briefly describe what repairs you are hoping to have done to your home:

What is your military experience?

Is anyone living in the home age 62 or older?

Are there any individuals who have special needs or need accommodations living in your home?

For eligibility purposes our program needs to know if anyone in your household has a disability that may qualify them for additional services or resources.

How many people live in your home?

What is your monthly household income?

In a regular month, what is the total income for all household members?

Are you current on your mortgage and property taxes?

How did you hear about us?

Contact Information