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William P. Kenoi Susan K. Akiyama Mayor Housing Administrator CountyofHawaii OFFICE OF HOUSING AND COMMUNITY DEVELOPMENT EXISTING HOUSING DIVISION 50 Wailuku Drive Hilo, Hawai’i 96720-2456 V/TT (808) 961-8379 FAX (808) 961-8685 RESIDENTIAL REPAIR PROGRAM APPLICATION (RRP) Application must be filled out COMPLETELY. Please use BLACK Ink to complete application. If any question does NOT apply, please acknowledge by writing NONE or NOT APPLICABLE. Do not leave any section unanswered. Be reminded that questions asked apply to ALL Household members. Please print or type. PART 1: GENERAL INFORMATION: APPLICANT (Head of Household): _________________________________________ Phone:________________________ Legal Last Name First Name MI CO-APPLICANT (Spouse or Co-Head): _________________________________________ Other Phone:___________________ Legal Last Name First Name MI Current Address: ____________________________________________________ Apt. No._______________ City: ___________________ State:________________________ Zip:___________ Yrs. at Residence:___________ Previous address if less than 2 yrs. at above ________________________________________ Yrs. at Residence:___________ Check here if mailing address is the same as current address. Mailing Address: ____________________________________________________ Apt. No.__________ City: _________________________________ State:________________________ Zip:______________ PART 2: HOUSEHOLD MEMBERS: Starting on first line for the Head of Household, please supply the information for all adults and children that will live in the housing unit to be assisted. List the adults first, then children. Enter one of the following codes in the “Relation” box to identify the household relationship of each adult and child listed.H = Head of Household K = Co-Head (Not Married) Y = Youth Under 18 L = Live In Aide S = Spouse (Married) F = Foster Child/ Adult E = Full Time Student Over 18 A = Other Adult Last Name & Sr, Jr, etc. First Name MI Date of Birth SexRelation H (Head of Household) 1 Single Race (select one or more) Ethnicity (check one box) \[ \] White \[ \] Asian \[ \] Black or African American \[ \] Hispanic or Latino \[ \] Native Hawaiian or Other Pacific Islander \[ \] Not Hispanic or Latino \[ \] American Indian / Alaska Native Multi Race (select one or more) \[ \] Asian and White \[ \] Other Multi-Racial \[ \] Black or African American and White \[ \] American Indian / Alaska Native and White \[ \] American Indian / Alaska Native and Black EQUAL HOUSING OPPORTUNITY “HAWAI`I COUNTY IS AN EQUAL OPPORTUNITY PROVIDER AND EMPLOYER” 7157rbla