Maricopa County Home Improvement Program (MCHIP) Inquiry Form
Maricopa County offers multiple types of assistance for income-eligible homeowners with home improvement, minor repairs, major rehabilitation, and energy efficiency services. Some programs may require forgivable liens (no payments or interest) to be placed upon the home. Individual program details will be discussed upon receipt of your inquiry. Directions: Fill out the confidential form below if you are a homeowner and interested in a home improvement program. Please note that completing this form should be considered a request for program information only. The form is not considered a pre-application or application form. Upon completion of the form, you will be contacted within 10 business days by a staff member to discuss your inquiry. If you require assistance with the completion of the form, or would like to request the form in paper or Spanish, please call 602-506-5911.
Referral Date:
Last Name:
First Name:
Gender:	M F
Street Address:
Apt/Unit/Suite:
City:
State:	AZ
ZIP:
Email Address:
Daytime Phone:
Phone Type:	Home Work Cell Message Bus Phone Bus Fax
Preferred Method Of Contact:	Phone Email
Primary Language:	English Spanish (No English) Other     If Other, please specify:
How did you hear about us?:	Friend Family Member Human Services Department CAP Office Website 211 Utility Company Referral Other If Other:
Household Size:
Annual Gross Household Income:	5,000-10,000 10,001-20,000 20,001-30,000 30,001-40,000 40,001-50,000 50,000+
Do You Own Home?:	Yes No
Is This Home your Primary Residence?:	Yes No
Are You On Title of Home?:	Yes No
Are You Current On Mortgage?:	Yes No
Is Home In Foreclosure?:	Yes No
Are You Current On All Property Taxes?:	Yes No
Do You Have Homeowners Insurance:?	Yes No
Select House Type:	Mobile Home Modular Single Family (Wood/Brick) Condo Townhouse Other
Year Home Was Built:
If not listed on deed, describe ownership details:
Utility Company (Select all that apply):	Checked Utility Company OTHER APS Southwest Gas SRP
Select Program Types:	Checked MCHIP Program Energy Efficiency Appliance Repair or Replace Home Repairs (Wait List Full)
Describe what you would like to have done to your home: