2022-2023 Home Repair Application

APPALACHIAN MINISTRIES of the SMOKIES HOME REPAIR APPLICATION

2021-2122 HOME REPAIR SEASON
In order to serve our clients better, we have provided an online application option. Please complete the following application. Download the required documents, date and sign this form, and hit submit. If you need to submit your forms in a different way, you can fax them to us at: 865-262-9076, or mail them to:

Appalachian Ministries of the Smokies (AMOS)

PO Box CN-71904

Jefferson City, TN 37760

If you have any questions you can call us, Monday-Friday 9:00a.m. to 4:00p.m. at:

865-475-5611
IMPORTANT INFORMATION:
- ALL REQUESTED DOCUMENTS MUST BE RECEIVED WITH YOUR COMPLETED APPLICATION.
- THE APPLICATION WILL NOT BE PROCESSED UNLESS ALL REQUIRED DOCUMENTATION IS RECEIVED.
PLEASE UPLOAD THE FOLLOWING DOCUMENTS WITH YOUR APPLICATION:
- CURRENT MORTGAGE PAYMENT STATEMENT OR TITLE AND DEED
- CURRENT UTILITY BILL
- PROOF OF INCOME OF EVERY PERSON IN THE HOUSEHOLD
- STAMPED PAID RECEIPT OF CURRENT YEAR PROPERTY TAXES
- VEHICLE REGISTRATION FOR ALL VEHICLES
SCAN THE ABOVE DOCUMENTS, SAVE IN PDF FORM, AND DRAG TO THE BOX BELOW.

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How I will be submitting my required documents:*
Name*

First Name, Middle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which County do you live in?*
Email
example@example.com
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.

Household Information*

	NAME_____________	RELATION (type in self on first line)	LAST 4 DIGITS OF S.S.#	AGE	G E N D E R	R A C E	VETERAN (Y/N)	INCOME PER PERSON
SELF
SPOUSE
CHILD
CHILD
CHILD
CHILD
OTHER
OTHER

HAVE YOU APPLIED FOR HOME REPAIR SERVICES WITH APPALACHIAN OUTREACH or APPALACHIAN MINISTRIES OF THE SMOKIES (AMOS) BEFORE?*

YESNO
IF YES, WHAT YEAR?
HAS APPALACHIAN OUTREACH OR APPALACHIAN MINISTRIES OF THE SMOKIES (AMOS) EVER WORKED ON YOUR HOME?*

YESNO
IF YES, WHAT YEAR?
HOW LONG HAVE YOU LIVED IN YOUR HOME?*
TYPE OF HOME LOAN?*
TYPE OF HOME?*
IF YOUR HOME IS FRAME STRUCTURE, WHAT YEAR WAS IT BUILT?*
DO YOU OWN PROPERTY OTHER THAN YOUR RESIDENCE?*

YESNO
IF YES, WHERE?
HAVE YOU FILED BANKRUPTCY?*

YESNO
IF YES, WHAT YEAR?
HAVE YOU APPLIED FOR SERVICES WITH OTHER ORGANIZATIONS?*

YESNO
IF YES, WHAT WAS THE NAME OF THE ORGANIZATION, DATE APPLIED FOR ASSISTANCE, AND THE DATE THE WORK (IF ANY) WAS COMPLETED?

MONTHLY EXPENSES (Put a 0 if it doesn't apply)*

	AMOUNT
MORTGAGE
FOOD
TRANSPORTATION/AUTO LOAN
PHONE/CELL
CABLE/SATELLITE
ELECTRICITY
WATER
HEATING/GAS
MEDICAL BILLS/MEDICATION
OTHER LOANS
MONTHLY INSURANCE PREMIUMS(CAR/LIFE/HEALTH)

MONTHLY INCOME (Put a 0 if it doesn't apply)*

	AMOUNT
PAYROLL CHECK STUB
SSI/SSDI AWARD LETTER
RETIREMENT
VETERAN AWARD
UNEMPLOYMENT
CHILD SUPPORT
AFDC/FAMILIES FIRST
FOOD STAMPS
WIC
OTHER
OTHER

DESCRIPTION OF NEED (MARK ALL THAT APPLY)*

ROOFDECKRAMPEXTERIOR PAINTINGYARD WORKINTERIOR PAINTINGGENERAL CLEANINGOTHER:
IF YOU SELECTED OTHER, PLEASE PUT A SHORT DESCRIPTION OF WORK NEEDED:
PLEASE READ AND SIGN THE STATEMENT BELOW:

I hearby understand that any work performed by Appalachian Outreach Ministries Home Repair Program is on a volunteer basis, as one neighbor helps another. Many of the volunteers are unskilled in nature, but work together to help those in need. I agree to not hold Appalachian Outreach Ministries, Carson-Newman University, or individual volunteers responsible for the queslity of services performed, AND, understand that all efforts will be made to achieve quality results.

I grant Applachian Outreach Ministries, its representatives, and employees, the right to take photographs of me, my family and my property. I aughorize Appalachian Outreach Ministries, its assignees and transferees, to copyright, use, and publish the same; in print and/or electronically. I agree that Appalachian Outreach Ministries may use such photographs of me and/or my family with or without my name and for any lawful prupose, including for example such purpose as publicity, illustration, advertising, and web content.

I affirm that all information I provide is truthful to the best of my knowledge and I understand that Appalachian Outreach Ministries does check public records to confirm all provided information.
Signature #1*

Clear
Signature #2

Clear
Date*

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

APPALACHIAN MINISTRIES of the SMOKIES HOME REPAIR APPLICATION

PLEASE UPLOAD THE FOLLOWING DOCUMENTS WITH YOUR APPLICATION: