Program Eligibility Questionnaire

PROGRAM ELIGIBILITY QUESTIONNAIRE

If you are interested in applying for a Home Repair Loan through Polk CDC, please complete the following questionnaire.

Home Repair Program Eligibility Questionnaire

Earned income (salaries, wages, commissions, tips, bonuses, etc.)
Business income
Interest or dividends
New Option
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
Yes
No
Not Applicable
Roof
Gutters / Downspouts
Windows
Furnace / Heat System
Exterior Stairs / Porches
Bathroom
Water System
Doors
Insulation / Weatherization
Septic / Sewer
Kitchen
Siding
Foundation
Chimney
Exterior Paint
Interior Paint
Other
There is no working heat source
There is no working water system
The roof is actively leaking
There is no working septic/sewer
Polk Community Development Corporation web site
County or city newsletter
Brochure
Family, friend or neighbor
Other
Enter your free text here

Get in Touch with Polk CDC!

Phone

Fax

(503) 831-3188

Email

Our Office

657 Main Street
Dallas, OR 97338

Mailing Address

P.O. Box 33
Dallas, OR 97338
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