NYC Build it Back Demographics Form

Thank you for registering with the NYC Build It Back Program. In order to comply with Federal Housing and Equal Opportunity regulations, we are required to report to the U.S. Department of Housing and Urban Development each applicant’s race and ethnicity, who registered for or received disaster recovery assistance. Only the head of your household is required to fill out this information.

* Indicates required fields.

Application ID or Service Request Number? *

Application ID Service Request Number

First Name: *

Last Name: *

Date of Birth: *

Month

Day

Year

Damaged Home Address

Street Address: *

City *

State *

ZIP Code *

Please select your race: *

Please select your ethnicity: *

Please select your gender: *

Are you a single (unmarried) head of household with children? *

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