Application for Service – Mountain Communities Fire Safe Council

Property Owner's Name *

First

Last

Participate

I agree to have the MSFSC evaluate my property and wish to participate in the project.

Present

I want to be present for the evaluation and have some recommendations.

Septic

I can help in locating the septic tank and leach lines.

Undeveloped

The property is undeveloped.

Sewer

This property is on the sewer system.

Understand

I understand that I will not be charged for services unless I sign an agreement once presented with the evaluation form.

Photos

I give consent to have photos taken of the property before and after work is performed.

I meet at least one of the following socio-economic criteria – I am 65 years or older, our household is low-income, I have a disability:

Yes
No

*This question assists us in determining the correct grant fund to use for your project. Local homeowners who do not meet any of those criteria will not be disqualified or prevented from participating in our programs.

This is my primary/principal residence: *

Yes
No

Tax Assessor Parcel Number (if known):

Street Address: *

Town: *

State: *

Zip Code: *

Mailing Address:

Best Phone Number: *

Email:

Acres (if known):

I understand that once my property has been properly abated through the MCFSC grant program, I should be able to maintain it for several years with simple hand tools and that it is my responsibility to do so. Grant funds are not intended to be used for on-going property clean-up. *

I understand

Signature/Print Name:

Date: