Dear Applicant, Please note that this is not a guarantee of grant funds. Household income will be verified to meet certain program requirements. Home-owners insurance, property taxes, and utility payments must be current. Limits on assistance apply. We will contact you as funding becomes available. If you have any questions, contact Region XII COG at 712-792-9914.
Full name
Street address
P.O. Box
City and county where your home is located
Phone number
Email address
Do you own your home? YesNo
Number of all children and adults living in the home?
Estimate gross annual income from all sources?
Is anyone in your household over the age of 62? YesNo
Is anyone in your household mentally/physically disabled? YesNo
Is anyone in your household a Veteran? YesNo
Describe your home repair/rehabilitation needs (e.g. roof, furnace, air conditioning, etcs.)?
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