Home Modifications for Independence (HMI)

First Name *

Last Name *

Phone Number

Email Address *

Who needs the Home Modification? *

I certify that I, or the person in need of the renovation, is a Pennsylvania resident. *

Does the recipient have a spinal cord injury and/or a different type of disability? *

Spinal cord injury Other type of disability I have no disability

Is the recipient 62 years or older? *

Yes No

Does the recipient reside in one of the following counties? Please select the one that applies. *

Allegheny Beaver Bedford Bucks Chester Cumberland Dauphin Delaware Fayette Greene Huntingdon Juniata Lancaster Mifflin Montgomery Northumberland Perry Philadelphia Other

Other County *

Home Modifications for Independence (HMI)

Are you interested in a home modification for yourself or someone else? To better support you, please fill out the form below.