Safe at Home West Sacramento - Eligibility List

If you are interested in this service for minor home safety modifications for low-moderate income seniors owning a home in West Sacramento, please fill out the following information and someone from the City or our partner Rebuilding Together Sacramento will contact you.

Question Title

* 1. What is the mailing address of the home hoping to receive minor safety modifications?

First & Last Name

Address

ZIP Code

Email Address

Phone Number

Question Title

* 2. Please answer the following questions.

	Yes - you may qualify	No - you might not qualify
Does the owner of this home live at the address listed above?	Does the owner of this home live at the address listed above? Yes - you may qualify	Does the owner of this home live at the address listed above? No - you might not qualify
Are you or someone in your household aged 50+?	Are you or someone in your household aged 50+? Yes - you may qualify	Are you or someone in your household aged 50+? No - you might not qualify
Would you qualify as low-moderate income?	Would you qualify as low-moderate income? Yes - you may qualify	Would you qualify as low-moderate income? No - you might not qualify

Question Title

* 3. Are you able to provide ONE of the following income verification documents for all members of the household who receive an income?

	Yes	No
Social Security award letter	Social Security award letter Yes	Social Security award letter No
Recent pay stub	Recent pay stub Yes	Recent pay stub No
Income tax return	Income tax return Yes	Income tax return No
Recent bank statement	Recent bank statement Yes	Recent bank statement No

Safe at Home West Sacramento - Eligibility List

Question Title

* 1. What is the mailing address of the home hoping to receive minor safety modifications?

Question Title

* 2. Please answer the following questions.

Question Title

* 3. Are you able to provide ONE of the following income verification documents for all members of the household who receive an income?

Question Title

* 4. Any additional questions or comments?