Name *

First Name

Last Name

Phone *

(###)

###

####

What is the best way to contact you? *

Please select your preferred contact method(s).

Email

Phone call

Text message

By mail

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Interest in a Buyout *

Please provide more information about your level of interest in a buyout.

I would like to receive a buyout as soon as possible.

I am still considering if a buyout is the right option for me and would like additional information.

Special Considerations *

Is anyone in your household elderly (65+) or living with a disability?

Yes

No

Permission for Buy-In Community Planning, Inc. to use this information. *

By checking this box, I certify that I understand the information I have provided above may be used to help me receive a buyout if funding becomes available. I authorize that all information provided on this form, including any and all personal data, may be shared with Buy-In Community Planning, Inc., an IRS approved 501(c)3, to facilitate the development of buyout programs in my area. I understand that my participation in a buyout program is entirely voluntary and I may withdraw my interest at any time. This data will be securely retained indefinitely.

I have read and acknowledge the permissions granted to Buy-In Community Planning, Inc. to use my information.