Minor Home Repair Program
5026 196th St SW Lynnwood, WA 98036-6102
Phone: 425.265.2222

IMPORTANT: You must be registered with our program before any repair service may be provided.

Don't wait for an emergency... Please submit your application today.

New Submission or Renewal

New or Returning?*

Contact Information

Please fill out your contact information below.
Todays Date
Name*
Address*
Gender*
Are you a veteran?*
Additional Family Member 1 Name
Additional Family Member 1 Birthdate
Additional Family Member 2 Name
Additional Family Member 2 Birthdate
Additional Family Member 3 Name
Additional Family Member 3 Birthdate
Is there a child 6 years or younger living in this home?*
Hispanic / Latino?*
Race*
Birthdate:*
You must submit proof of age. If you are under 62, you must submit proof of disability. This information may be uploaded below or mailed to Homage separately.

Household Monthly Income and Age/Disability

Proof of Age or Disability and Proof of Current Income (Send mail to: Minor Home Repair, Homage, 5026 196th St SW, Lynnwood, WA 98036)*
File Proof of Age
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your age or disability.

Please enter your current income for all household members. (If a box does not apply leave it blank.)

$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Social Security income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Supplemental Social Security income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Social Security Disability income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Pension or Retirment income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Gross Wages.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your Interest Earned
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current IRA/Annuity Income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Unemployment Income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Rental Income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Income From Other Sources.

Home Information

Type of residence*
Ownership*

    If you occupy the home under a Lifetime Rights Agreement, the owner MUST complete the Lifetime Rights Agreement statement, have it notarized, and mail or upload it with the application. If you need a Lifetime Rights Agreement statement you can print it here or contact our office.

File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload the notarized Lifetime Rights Agreement.
Is your home listed for sale?*
Please Note: You are required to notify Minor Home Repair immediately upon listing your home for sale.
Value in years.
Emergency Contact Name (not living with you)
I have an Emergency repair need

Please note: You are required to notify Minor Home Repair immediately to report any changes in the total household income or any change to the number of people living in the home.

PLEASE READ CAREFULLY:

In consideration of any Minor Home Repair service rendered pursuant to this application, the undersigned hereby waives any claim for damages to persons and/or property arising from such services, and further understands and agrees that no warranty, express or implied, is made as to the quality of material or workmanship. By my initials entered below which serves as my electronic signature, I hereby agree that Minor Home Repair may contact any persons and/or private or governmental entity necessary to verify the information contained herein. Further, I affirm, under penalty of law, that the information given above is true and accurate to the best of my knowledge, I realize that willful falsification by me may render me ineligible for Minor Home Repair services and may subject me to penalties as provided in Washington State Law. (RCW 74.08.0056)

Type your first and last name.
Date*

Renewal Information

Name *
Address*
Is this a home phone or a cell phone number?
Birthdate:*
You must submit proof of age. If you are under 62, you must submit proof of disability. This information may be uploaded below or mailed to Homage separately.
Is there a child 6 years or younger living in this home?*
Proof of Current Income (Send mail to: Minor Home Repair, Homage, 5026 196th St SW, Lynnwood, WA 98036)*

Please enter your current income for all household members. (If a box does not apply leave it blank.)

$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Social Security income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Supplemental Social Security income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Social Security Disability income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Pension or Retirment income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Gross Wages.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your Interest Earned
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current IRA/Annuity Income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Unemployment Income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Rental Income.
$
File
No File Chosen
File uploads may not work on some mobile devices.
Mail or upload proof of your current Income From Other Sources.

Please note: You are required to notify Minor Home Repair immediately to report any changes in the total household income or any change to the number of people living in the home.

PLEASE READ CAREFULLY:

In consideration of any Minor Home Repair service rendered pursuant to this application, the undersigned hereby waives any claim for damages to persons and/or property arising from such services, and further understands and agrees that no warranty, express or implied, is made as to the quality of material or workmanship. By my initials entered below which serves as my electronic signature, I hereby agree that Minor Home Repair may contact any persons and/or private or governmental entity necessary to verify the information contained herein. Further, I affirm, under penalty of law, that the information given above is true and accurate to the best of my knowledge, I realize that willful falsification by me may render me ineligible for Minor Home Repair services and may subject me to penalties as provided in Washington State Law. (RCW 74.08.0056)

Type your first and last name.
Date*
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