APPLY FOR HOME REPAIR ASSISTANCE

Home Repair Request Form- #ICARE❤️

Please take the time to explain the situation you are currently facing so that we can make the best decision as to the help we may be able to provide.

* Indicates required field

Email *

Full Name *

Address of the Property *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone *

Date of Birth (mm/dd/yyyy) *

Are you married, live with someone, or single? You may live with an elderly parent and need assistance, so please explain the details under “other” if needed. *

Married/Partner Single Other

Other *

Do you have any children or dependents? If so, how many live with you? Do you care for any others in your home? *

Is this the first time you are reaching out to us for help? *

Yes No

What are you seeking help with? What are the issues you need help with at your house? Please be as specific as possible. *

Do you have any resources that can be spent on this project? *

Yes No

Please describe what you may have to offer to help with this project. It could be materials you already have, labor you can provide or a financial contribution of some kind towards the project. *

Any additional comments or information you’d like for us to know that may impact our decision? *

Disclaimer:

Hamptons Community Outreach ("HCO") is a non-profit, 501(c)(3) charitable organization that provides limited goods and services such as crisis intervention, enrichment services and mental health support to underserved people living all over the East End of Long Island. Assistance is provided by HCO to those in need of help in a non-discriminatory manner, based upon certain criteria such as the needs of the applicants, the availability of resources and the ability of HCO to respond to the applicant's request in a meaningful manner. The acceptance of applicants and the provision of goods and services is solely at the discretion of HCO, and HCO reserves to itself the right to decline applicants or deny the provision of goods and services as it deems fit given the circumstances presented.

Please submit this form and email the first page of your 1040 tax return to housing@hamptonscommunityoutreach.org in order to complete your application. In addition, please send any photos you may have of the work that is needed. All submissions and documentation shared with us will be used solely for the purpose of making a determination as to whether we can assist you or not and to what extent. All information you submit will be kept under strict confidence and is only shared with the executive director of Hamptons Community Outreach. Thank you for your interest in our program.

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Home Repair Request Form- #ICARE❤️

Hamptons Community OutreachP.O. Box 838Bridgehampton, NY 11932Phone: (631) 488-8715Email: info@hamptonscommunityoutreach.org​Follow us:

Hamptons Community Outreach
P.O. Box 838
Bridgehampton, NY 11932
Phone: (631) 488-8715
Email: info@hamptonscommunityoutreach.org

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