Home Rehabilitation Program Inquiry For information on Home Rehabilitation. Date: Name: Address: Home Phone: Work or Message Phone: Is your home located within city limits? Yes No What neighborhood or area? Have you owned & occupied your home for the past year? Yes No Household income: $ Source of Income: Is the head of household a female? Yes No Family Size Have you had a previous Home Rehab with the City of Albuquerque? (must be 10 years or more) Yes No If yes, date? How did you hear about the program? Program Eligibility Occupant Self-Assessment for Type of Rehab Requested. Structural Yes No Electrical Yes No Plumbing Yes No Heating Yes No Roof Yes No Additional Household Information Do You Have a Reverse Mortgage? Yes No Is your home a Mobile Home? Yes No If your home is a Mobile Home, is it on a permanent foundation? Yes No Has the property been red tagged by PNM? Yes No Has the property been cited for code violations? Yes No Has the property had a Referral from Safe City Strike Force? Yes No Are there any safety or life threatening risks resulting from the house’s condition? (Explain) Number of elderly in household (62 yrs. or more) Number of children in household (18 yrs. or less) Who and what family/resources do you have to help you move & temporarily relocate during construction?