Form Center

Step One

All applicants must be a resident of Bloom Township.
Application Date
Application Date
Demographic Information
Name of Applicant
Property Addess
Home Phone Number
Work Phone Number
Cell Phone Number
Email Address
Do you currently live at this residence?
1. Yes
2. No (You must reside at the residence where the ramp is needed.)
Do you own this property?
1. Yes
2. No
If you own this property, please list the names on the deed.
Applicant must own property to be eligible for Ramp Program.
Do you or someone in your household have a permanent physical disability?
1. Self
2. Other
Please list: name, relationship, and disability (you must list: person, disability, age of onset or we will not process your application)
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Co-Applicant Name (If name is on the deed)
Marital Status
1. Married
2. Single
3. Divorced
4. Widow/Widower
Home Phone Number
Work Phone Number
Cell Phone Number
Email Address
Household Composition
Number of People Living in the Residence (Including Applicant)
List Each Resident and Their Age, Relationship to Applicant, and Disability Status
Resident One
Name
Relationship
Age
Disability? Yes/No and List Disability
Resident Two
Name
Relationship
Age
Disability? Yes/No and List Disability
Resident Three
Name
Relationship
Age
Disability? Yes/No and List Disability
Resident Four
Name
Relationship
Age
Disability? Yes/No and List Disability
Resident Five
Name
Relationship
Age
Disability? Yes/No and List Disability
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Financial – Include Income for All Housing Residents - All household income must be verified. This includes any income on behalf of minors, employment income and/or child support. Upon request you shall be required to send copies of Pension, Retirement, Workers Compensation, Social Security/SSI support letters, and current pay stub (if employed). Please provide monthly dollar amounts below.
Income in Dollars from Social Security
Income in Dollars from SSI/SSDI
Income in Dollars from Pension
Income in Dollars from Child Support
Income in Dollars from Unemployent Compensation
Income in Dollars from Worker's Comp
Income in Dollars from Public Assistance
Income in Dollars from Employment (Including Bonuses, Commission, and Self-Employment Income)
Income in Dollars from Other Sources
Total Amount of Monthly Income
Mortgage Information
Are mortgage payments current?
1. Yes
2. No
Are taxes paid to date?
1. Yes
2. No
Insurance Information
Do you have homeowner's insurance coverage?
1. Yes
2. No
Name and Address of Insurance Company
Policy Number
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I/We acknowledge that the information I/We have provided in this application is true and accurate to the best of my/our knowledge.
Signature of Applicant
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Date
Date
Signature of Co-Applicant
Electronic Signature Agreement
By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.
1. I agree.
Electronic Signature
Date
Date
Please be advised that the ramp program provides wheelchair accessible ramps only. No other home modifications are included in the program. Understand you might be placed on a waiting list until funding is available

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