Lebanon Repair Form

Applicant Name(s) (required)

Address (required)

City (required)

State (required)

Zip Code (required)

Home Phone

Email

Do you currently live or work in Lebanon County?
yesno

Do you live in Southwest Lancaster City, Elizabethtown, Lancaster, East Petersburg or Lititz?
yesno

Are you a homeowner?
yesno

Are you a US Citizen or a legal permanent resident?
yesno

Are you and the members of your household willing to work volunteers hours on the repair project?
yesno

Work Phone

Si necesita una forma en espanol, por favor, manda un correo a family@llhfh.org o llama a la oficina a 717.392.8836

Please describe the repair you need