Aging Services Home Repair & Accessibility Program Application

Aging Services enhances the lives of older adults by providing services and resources to assist them in remaining independent.


The Home Repair & Accessibility Program assists with small home repairs to help maintain and/or improve home safety and function for individuals aged 60 and over.


Please note that the Home Repair & Accessibility Program focuses on basic health and safety issues that can be resolved for less than $300. We attempt to complete these projects with the least expensive resolution. We prioritize projects based on which are most dangerous if left unattended over time. Our ability to assist with any Home Repair & Accessibility Project is dependent upon funding and volunteer availability.


The Home Repair & Accessibility Program is unable to provide:

  • Appliances or appliance repairs (including furnaces, garbage disposals, etc.)
  • Cosmetic repairs (including painting, carpet cleaning, mobile home skirting, etc.)
  • Household chores (including laundry, dishes, vacuuming, etc.)
  • Emergency repairs or services

Individuals interested in receiving Home Repair & Accessibility services may begin the application process by completing each section of this online form. The application is a requirement of the Program and is necessary based on the guidelines of the agencies providing funding for our services. Our staff will follow up with you regarding program eligibility and next steps as applicable.


Aging Services and its programs will consider this application without regard to race, color, creed, religion, national origin, sex, sexual orientation, disability, age, marital status, public assistance status, genetic or family medical history, or any other protected classification under local, state, or federal law.

Demographic Information












List any other adults who live with you:












Please indicate you agree to the following statements by selecting 'I agree' and signing your name. 





Authorization for Release of Information









I hereby authorize Aging Services and the Home Repair & Accessibility Program to release to and exchange relevant information with the following:
  • Case Manager at Managed Care Organization

Prohibition on Re-disclosure
This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected by federal law for alcohol/drug abuse records or by state law for mental health records, federal requirements (41 D.F.R. Part 2) and state requirements (Iowa Code ch. 228) prohibit further disclosure without the specific written consent of the patient, or as otherwise permitted by such law and/or regulation. A general authorization for the release of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may attach for unauthorized disclosure of alcohol/drug abuse or mental health information.



Financial Assistance

Financial assistance is available for those who would like assistance in covering all or part of any potential projects, Lawn Mowing services, or Snow Removal services. To be considered for financial assistance, you will need to complete a Financial Assistance Application form for all members of the household. To verify your eligibility, you will need to submit complete copies of bank statements for all members of the household.


If you indicate below that you are interested in applying for financial assistance at this time, you will be sent the financial assistance application upon completion and submission of this application form. 


If you are not interested in financial assistance, you will be responsible for the full cost of any projects you request. You will be offered an estimate for the full cost of any requested projects which will need your approval before any work will be done.


Financial assistance can be applied for at any time by completing a financial assistance application and providing a copy of a recent bank statement. Financial assistance applications are available from our office.


Authorization for Release of Information

I hereby authorize Aging Services and the Home Repair & Accessibility Program to release to and exchange relevant information with the following individuals and agencies:
  • Home Repair & Accessibility Program service providers and volunteers
  • Emergency or Family Contact listed below
  • Additional individuals listed below, if any (friends, family members, caregivers, physicians, etc.)

Prohibition on Re-disclosure

This form does not authorize re-disclosure of medical information beyond the limits of this consent. Where information has been disclosed from records protected by federal law for alcohol/drug abuse records or by state law for mental health records, federal requirements (41 D.F.R. Part 2) and state requirements (Iowa Code ch. 228) prohibit further disclosure without the specific written consent of the patient, or as otherwise permitted by such law and/or regulation. A general authorization for the release of medical or other information is not sufficient for these purposes. Civil and/or criminal penalties may attach for unauthorized disclosure of alcohol/drug abuse or mental health information.






Enter name, phone number and relationship of additional individuals you are authorizing



Home Liability Waiver

The goal of the Aging Services Home Repair & Accessibility program is to help older adults remain safely in their home. We make every attempt to ensure the safety of our participants and will attempt to fix original home repair requests to the best of our ability. Unfortunately, in our experience, we have found that it may be difficult to find a contractor or volunteer that has the tools necessary to complete home repairs satisfactorily due to the age, materials, and/or structure of some homes.








Consumer Intake Questions

The services you are receiving is paid for entirely or partially by funds from the federal Older Americans Act and the State of Iowa. Your responses on this form are confidential. This information is used to comply with reporting requirements and research the needs of older Iowans. Thank you.