SayPro Repair Request Form Template for Home Repair Programs.

Program Name: SayPro Monthly Home Repair Programs – January 2025 (SCDR-1)
Offered by: SayPro Community Development Office
Program Overview: The SayPro Home Repair Program offers assistance to eligible homeowners for critical home repairs and improvements. This service is provided under the SayPro Development Royalty initiative (SDR) and aims to assist low-income families, elderly individuals, and those with disabilities.

Please complete the form below to request home repairs for your residence. Once submitted, you will receive a confirmation email with your request ID number. A representative will contact you regarding the next steps and to schedule an assessment of your home’s needs.

Participant Information

1. Full Name of Homeowner:
   • (First Name) (Last Name)
2. Address of Home Needing Repairs:
   • (Street Address, City, State, Zip Code)
3. Phone Number:
   • (Primary Phone Number)
   • (Alternate Phone Number, if available)
4. Email Address:
   • (Your Email Address)
5. Preferred Method of Contact:
   • Phone
   • Email
   • Text Message
6. Best Time to Contact:
   • Morning (9 AM – 12 PM)
   • Afternoon (12 PM – 3 PM)
   • Evening (3 PM – 6 PM)
7. Are you the homeowner or a representative submitting this request?
   • Homeowner
   • Representative (Please provide contact info for the homeowner if different from above.)

Property Information

8. Type of Property:
   • Single-family Home
   • Duplex
   • Townhouse
   • Condo/Apartment
   • Mobile Home
   • Other: ___________
9. How long have you lived at this property?
   • Less than 1 year
   • 1-5 years
   • 5+ years

Repair Request Details

10. Please select the type(s) of repair or improvement needed:

• Plumbing:
  • Leaky Faucets
  • Pipe Replacement/Repair
  • Clogged Drains
  • Toilet Repairs
  • Water Heater Issues
  • Other: ___________
• Electrical:
  • Outlet Replacement
  • Wiring Issues
  • Lighting Fixtures
  • Fuse/Breaker Box Repair
  • Other: ___________
• Roofing:
  • Leaky Roof
  • Roof Shingle Replacement
  • Gutter Repair
  • Other: ___________
• HVAC (Heating, Ventilation, and Air Conditioning):
  • Furnace Repair/Replacement
  • Air Conditioning Repair
  • Ductwork Repair
  • Other: ___________
• General Home Repairs:
  • Window Repair/Replacement
  • Door Repair/Replacement
  • Drywall Patching
  • Painting (Interior/Exterior)
  • Flooring Repair
  • Other: ___________
• Safety & Accessibility:
  • Grab Bars Installation
  • Ramp Construction
  • Stairlift Installation
  • Smoke/Carbon Monoxide Detector Installation
  • Other: ___________

11. Priority of Repair:

• Urgent (Immediate/Within 1-2 weeks)
• Medium (1-3 weeks)
• Non-Urgent (Can wait longer)

12. Please describe in detail the issue(s) requiring repair (Include any additional information that will help us assess the situation, such as the age of equipment or previous attempts at repair):

(Text box for detailed description)

13. Is there any immediate danger or health concern related to this repair request?

• Yes (Please describe: ___________)
• No

Eligibility Information

14. Do you meet the following eligibility criteria?

• I am a homeowner (I own the property at the address provided).
• I am a low-income homeowner, elderly (65+), or have a disability (Please provide any supporting documentation, if applicable).

15. Please attach any necessary documentation:

• Proof of income (for low-income eligibility)
• Proof of age (for elderly eligibility)
• Proof of disability (for disability eligibility)
• (Upload Section: Attach Documents Here)

Consent and Acknowledgment

By submitting this repair request form, you agree to the following:

• Consent to Assessment: I consent to a home inspection and repair assessment by SayPro contractors or volunteers to determine the repairs needed.
• Privacy and Data Protection: I understand that the information provided will be used solely for the purpose of assisting with the home repair program and will be kept confidential.
• Program Participation: I understand that submission of this form does not guarantee approval or immediate action. Participation is subject to availability, eligibility, and program resources.

Signature of Homeowner or Authorized Representative: (Please sign or type your name)
Date: (MM/DD/YYYY)

After Submission

• Confirmation: Once you submit this form, you will receive an email confirming your request. Please save your request ID number for future reference.
• Next Steps: A SayPro representative will contact you within the next 7-10 days to schedule an in-person assessment of your home. During this assessment, we will evaluate your repair needs and determine the scope of services we can provide.
• Contact Us: If you need assistance with this form or have any questions, please contact SayPro’s Community Development Office at [phone number] or [email address].

Important Notes:

• Program Limitations: Due to limited resources, we may not be able to fulfill all repair requests. Priority will be given to low-income, elderly, and disabled homeowners.
• Volunteers & Contractors: Repairs will be completed by trained volunteers and local contractors. If your repair needs require specialized skills or materials, we will work with you to find the best solution.
• Safety: Please ensure that your home is accessible and safe for contractors and volunteers during the assessment and repair process. All work will be done in compliance with safety standards and regulations.

This form template provides the necessary structure to capture all relevant information for participants requesting home repairs under the SayPro Monthly Home Repair Programs. It ensures that the process is organized, accessible, and able to efficiently manage repair requests from the community.