2020-2021 Home Repair Application

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 Outreach Ministries

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.

Browse Files

How I will be submitting my required documents: *

Name *

First Name, Middle Initial Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Which County do you live in? *

Email

example@example.com

Home Phone Number *

Area Code Phone Number

Cell Phone Number

Area Code Phone Number

Household Information *

APPLICANT'S 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

OTHER

HAVE YOU APPLIED FOR HOME REPAIR SERVICES WITH APPALACHIAN OUTREACH BEFORE? *

YES NO

IF YES, WHAT YEAR?

HAS APPALACHIAN OUTREACH EVER WORKED ON YOUR HOME? *

YES NO

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? *

YES NO

IF YES, WHERE?

HAVE YOU FILED BANKRUPTCY? *

YES NO

IF YES, WHAT YEAR?

HAVE YOU APPLIED FOR SERVICES WITH OTHER ORGANIZATIONS? *

YES NO

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

DESCRIPTION OF NEED (MARK ALL THAT APPLY) *

ROOF DECK RAMP EXTERIOR PAINTING YARD WORK INTERIOR PAINTING GENERAL CLEANING OTHER:

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 *

Date

Please verify that you are human *

APPALACHIAN OUTREACH MINISTRIES HOME REPAIR APPLICATION

PLEASE UPLOAD THE FOLLOWING DOCUMENTS WITH YOUR APPLICATION: