Rehab/Repair and Accessibility Modification Screening Form

Ask for Help for Home Rehab/Repair or Accessibility Modification

ORHA keeps a list of households who need help and might be eligible for the types of programs we administer. When funding is available, we work from this list to invite families to apply for assistance. We also use this list to help show our funders that there are families in the area who need our help.

If you are a resident of Otsego County and would be interested in receiving help from ORHA’s home repair/rehabilitation and accessibility modification programs, you can complete the following form to share some initial information with us. If it seems like you could be eligible for current or future programs, we will add you to our list.

This form is not an application for any specific program. Completing and submitting it does not guarantee you will get help from ORHA.

This form is also not for rent assistance programs. If you are looking for help with paying your rent, please click here to visit our Section 8 page.

Need a paper version instead? Download our paper intake form by clicking here.

Initial Screening Form



Co-Head of Household Name:





What is the home's physical address?


What is your mailing address?


About Your Household

Head of Household's date of birth:

How many people live in your home, including you?

Please list everyone else (including the co-head of household) who lives in the home. Provide each person's name, date of birth, and relationship to the head of household (e.g., child, parent, grandchild, spouse). You may also include any other information about a household member that you think ORHA should know, including alternate contact information like a co-head's phone number or email address.


How many children (minors under 18) live in your home?

How many seniors (people age 60 or over) live in your home?

How many people with disabilities live in your home?

Are you or anyone else living in the household a veteran?
If a veteran in your household is entitled to receive payments due to a disability incurred in a time of war, please select the "Yes - Disability Incurred During Wartime" option.
What is the gross annual income for your entire household? Include all income for every adult living in your home and all non-employment income for any minors.
Your gross income is your income before any taxes or deductions are taken out of it.

Do you receive benefits from any of the following programs? Select all that apply.
Select multiple areas by holding down control (PC) or command (Mac).

About Your Home

Is this your primary residence?
What parts of the home are you looking for help with?
Select multiple areas by holding down control (PC) or command (Mac).

Tell us why you need help with these parts of the home. Please describe the problem(s) in detail. Include any other information you think could be helpful, such as a recent contractor's recommendation/quote, your ideal solution, a warning you got from your insurer, negative effects the issue is having on your life, other repair programs that have already helped or denied you, etc.


How would you rate the current overall condition of your home?
Is your home a mobile or manufactured home?
In roughly what year was your home built?
Use your best guess if you aren't sure.

Do you own this property? Please select the category that best describes you.
Who owns this home? Please list all of the owners named on the current deed/title for the property, including the remaindermen of life estates.
If you rent and aren't sure of all owners, you may list the one(s) you do know of.

Are you current on all payments for any mortgage or other loan secured by the property?
Renters should skip this question.
Do you carry homeowner's insurance on the property?
Renters should skip this question.
Are you current on all taxes on the property? This includes school, town, county, and village taxes.
If you aren't responsible for the property taxes because you are a lot renter or a renter, you can skip this question.
What municipality do you pay your property taxes to?
If you aren't responsible for the property taxes, select the municipality the home is located in. This may be different from the city/town listed in your address. If you're registered to vote at this address, this will be the city/town whose elections you can vote in.

Housekeeping Questions

How did you find out about ORHA?

If this form is not being completed by the head of household, please provide your name here. If you are not a member of the household, please also list your relationship to the household, organization (if applicable), and contact information.

Certify & Submit

By clicking the "Agree & Submit" button below, you are certifying that you have done your best to honestly and accurately answer these questions.

By clicking the "Agree & Submit" button below, you acknowledge that this form is an initial screening form only. It is not an application for any specific ORHA program. Submitting this form does not guarantee that ORHA will assist you.


This form was developed with funding assistance from Housing Trust Fund Corporation and NYS Homes and Community Renewal.