HUG Program Application (Home Repairs Only additional entries will be vacated)

Housing Authority of Clayton County
8:30 am - 4:30 pm Monday - Friday
732 Main Street
Forest Park, GA 30297
404.362.1200
(ext. 204 for General Inquiries)
(ext. 203 for HUG Program Inquiries)

Fields marked with * must be completed or form will not submit.

[{"type":"text","required":true,"label":"1. Full Name","name":"1-Full-Name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"1. Date of Birth","name":"1-Date-of-Birth","className":"col-md-6","subtype":"text"},{"type":"text","label":"1. Age","name":"1-Age","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"1. Gender","name":"1-Gender","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"1. Race","name":"1-Race","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"1. Ethnicity","name":"1-Ethnicity","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"radio-group","label":"1. Are you a veteran?","inline":true,"name":"1-Are-you-a-veteran","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"text","subtype":"email","label":"1. Email","name":"1-Email","className":"col-md-6"},{"type":"text","subtype":"tel","label":"1. Phone","name":"1-Phone","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"text","required":true,"label":"2. Full Name","name":"2-Full-Name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"2. Date of Birth","name":"2-Date-of-Birth","className":"col-md-6","subtype":"text"},{"type":"text","label":"2. Age","name":"2-Age","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"2. Gender","name":"2-Gender","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"2. Race","name":"2-Race","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"2. Ethnicity","name":"2-Ethnicity","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"radio-group","label":"2. Are you a veteran?","inline":true,"name":"2-Are-you-a-veteran","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"text","label":"2. Email","name":"2-Email","className":"col-md-6","subtype":"text"},{"type":"text","label":"2. Phone","name":"2-Phone","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"radio-group","label":"Are you the home owner?","inline":true,"name":"Are-you-the-home-owner","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"text","label":"If \"No\" please provide your full name.","name":"If-No-please-provide-your-full-name","className":"col-md-6","subtype":"text"},{"type":"text","label":"Relationship to home owner?","name":"Relationship-to-home-owner","className":"col-md-6","subtype":"text"},{"type":"text","subtype":"email","label":"Email","name":"Email","className":"col-md-6"},{"type":"text","subtype":"tel","label":"Phone","name":"Phone","className":"col-md-6"},{"type":"radio-group","label":"Is home a single family detached dwelling?","inline":true,"name":"Is-home-a-single-family-detached-dwelling","className":"col-md-6","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"radio-group","label":"Any deed or title problems?","inline":true,"name":"Any-deed-or-title-problems","className":"col-md-6","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"text","label":"1st Name on Deed:","name":"1st-Name-on-Deed","className":"col-lg-4","subtype":"text"},{"type":"text","label":"2nd Name on Deed:","name":"2nd-Name-on-Deed","className":"col-lg-4","subtype":"text"},{"type":"text","label":"3rd Name on Deed:","name":"3rd-Name-on-Deed","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Deed Address","name":"Deed-Address","className":"d-block","subtype":"text"},{"type":"text","label":"City","name":"City","className":"col-lg-4","subtype":"text"},{"type":"text","label":"State","name":"State","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Zip","name":"Zip","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Is your home located in Clayton County?","inline":true,"name":"Is-your-home-located-in-Clayton-County","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"radio-group","label":"Is home in city limits of Forest Park or Morrow?","inline":true,"name":"Is-home-in-city-limits-of-Forest-Park-or-Morrow","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"radio-group","label":"Do you have current insurance on home?","inline":true,"name":"Do-you-have-current-insurance-on-home","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"text","label":"Number of Bedrooms","name":"Number-of-Bedrooms","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Number of Baths","name":"Number-of-Baths","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Amount of monthly mortgage payments (P/I T/I)","name":"Amount-of-monthly-mortgage-payments-PI-TI","className":"col-lg-4","subtype":"text"},{"type":"text","label":"How long have you lived at this address?","name":"How-long-have-you-lived-at-this-address","className":"d-block","subtype":"text"},{"type":"textarea","required":true,"label":"List all household members, including yourself.","name":"List-all-household-members-including-yourself","subtype":"textarea","className":"d-block"},{"type":"text","label":"Select the number of household members, including yourself.","name":"Select-the-number-of-household-members-including-yourself","className":"d-block","subtype":"text"},{"type":"text","label":"What is your total gross annual household income, before dedutions?","name":"What-is-your-total-gross-annual-household-income-before-dedutions","className":"d-block","subtype":"text"},{"type":"radio-group","label":"Do you have a septic or sewer waste system?","inline":true,"name":"Do-you-have-a-septic-or-sewer-waste-system","className":"d-block","values":[{"label":" Septic","value":" Septic"},{"label":" Sewer","value":" Sewer"}]},{"type":"radio-group","label":"Are there any gas leaks?","inline":true,"name":"Are-there-any-gas-leaks","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":"No"}]},{"type":"radio-group","label":"Do you have any electrical hazards?","inline":true,"name":"Do-you-have-any-electrical-hazards","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"radio-group","label":"Is there any part of your house about to collapse?","inline":true,"name":"Is-there-any-part-of-your-house-about-to-collapse","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"radio-group","label":"Are there any sewer issues, such as water or waste backing up into the house?","inline":true,"name":"Are-there-any-sewer-issues-such-as-water-or-waste-backing-up-into-the-house","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":"No"}]},{"type":"radio-group","label":"Are there severe sewer problems?","inline":true,"name":"Are-there-severe-sewer-problems","className":"d-block","values":[{"label":" Yes ","value":" Yes"},{"label":" No","value":" No"}]},{"type":"radio-group","label":"Do you have a working heater?","inline":true,"name":"Do-you-have-a-working-heater","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":"No"}]},{"type":"radio-group","label":"Do you have any major structural problems?","inline":true,"name":"Do-you-have-any-major-structural-problems","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"radio-group","label":"Does the roof leak?","inline":true,"name":"Does-the-roof-leak","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"radio-group","label":"Is the roof in imminent danger?","inline":true,"name":"Is-the-roof-in-imminent-danger","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"radio-group","label":"Do you have any unstable floors (i.e. rotten floor or feeling of unsafe footing)?","inline":true,"name":"Do-you-have-any-unstable-floors-ie-rotten-floor-or-feeling-of-unsafe-footing","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"textarea","label":"Describe repairs needed of an emergency nature:","name":"Describe-repairs-needed-of-an-emergency-nature","subtype":"textarea","className":"d-block"},{"type":"radio-group","label":"Are there any health concerns that are impacted by the repairs needed?","inline":true,"name":"Are-there-any-health-concerns-that-are-impacted-by-the-repairs-needed","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"textarea","label":"If yes, list them below:","name":"If-yes-list-them-below","subtype":"textarea","className":"d-block"},{"type":"radio-group","label":"<div>Have you received assistance for Home Rehabilitation from the Housing Authority of Clayton County in the <span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">past?</span></div>","inline":true,"name":"Have-you-received-assistance-for-Home-Rehabilitation-from-the-Housing-Authority-of-Clayton-County-in-the-past","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"text","label":"If yes, when?","name":"If-yes-when","className":"d-block","subtype":"text"},{"type":"radio-group","label":"Have you attempted to apply for home rehabilitation/repair needs from other programs?","inline":true,"name":"Have-you-attempted-to-apply-for-home-rehabilitationrepair-needs-from-other-programs","className":"d-block","values":[{"label":" Yes","value":" Yes"},{"label":" No","value":" No"}]},{"type":"textarea","label":"Program Collaboration: How did you hear about our services?","name":"Program-Collaboration-How-did-you-hear-about-our-services","subtype":"textarea","className":"d-block"},{"type":"header","subtype":"h4","label":"Application Certification","className":"d-block"},{"type":"checkbox-group","required":true,"label":"<div>By checking this box, I certify that the information provided on this form is true and accurate to the best of my <span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">knowledge. I am aware there are penalties for willfully and knowingly giving false information. I authorize verification </span><span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">by the Housing Authority of Clayton County representatives, and I will provide supporting documentation upon </span><span style=\"font-family: var(--bs-body-font-family); text-align: var(--bs-body-text-align);\">request.</span></div>","inline":true,"name":"By-checking-this-box-I-certify-that-the-information-provided-on-this-form-is-true-and-accurate-to-the-best-of-my-knowledge-I-am-aware-there-are-penalties-for-willfully-and-knowingly-giving-false-information-I-authorize-verification-by-the-Housing-Authority-of-Clayton-County-representatives-and-I-will-provide-supporting-documentation-upon-request","className":"d-block","values":[{"label":"I have read and agree to the above terms.","value":"I have read and agree to the above terms."}]},{"type":"text","required":true,"label":"Name","placeholder":"Disclaimer: By typing your name, you are signing this document.","name":"Name","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date ","name":"Date","className":"col-md-6"}]

HUG Program Application (Home Repairs Only additional entries will be vacated)

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