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Welcome to the Town of Payson, AZ, Action Line

Today is Saturday, November 21, 2009.
Housing Rehab Program - Pre-Screening Form
WARNING! Please do not use this form to report issues of an emergency nature or for conditions requiring an immediate response. If your issue is an emergency, please use the telephone and dial 911.

Purpose. Please complete this form to help us determine your eligbility for the Housing Rehab Program.

* Information is required.

Contact Information

* First Name:
* Last Name:
Email:
* Daytime Phone: ()  –
* Address:
* City:
* State:
* ZIP:

* Do you live in Payson?
Yes
No
 
* Do you live in a house or a manufactured home?
 
* Do you own the residence and the property on which your home sits?
Yes
No
 
* Do you have a mortgage on your home?
Yes
No
 
If yes, what company is it with?
 
* How many people live in your home?
 
* What is your total annual income? (Income includes gross wages, salaries, commission, tips and bonuses, as well as Social Security, welfare assistance, child support, periodic payments, interest, dividends and other regular payments.)
 
* What is the age of the head of household?
 
* Are any persons in the home disabled?
Yes
No
 
If yes, please explain:
 
What are your current housing needs and problems?
 
Check here to have email confirmation of this request sent.

* Information is required.

Notes:

If you send us a message, you'll receive a Tracking Number allowing you to follow-up with your request, at your convenience.

Information we receive may be considered public information which is subject to disclosure under current state law. Learn more about our Privacy Policy.

Internal Use Only, Leave Blank:
Please leave this field blank and remove any values that have been populated for it.

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