General Intake and Application Form for Home Repair

General Intake and Application Form for Home Repair
General Intake and Application Form for Home Repair
Applicant Name *

First Name Last Name
Owner Name *

First Name Last Name
Property Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Best way to reach you? *
Best time to reach you? *
Relationship to Applicant *
Emergency Contact *
Total Number of Adults Living in the Home (18+) *
Total number of children living in the home *
Tell us about why this owner and home should be selected for our program? *
Please explain why the owner cannot complete the repairs themselves. *
Are any able-bodied household members willing to assist in repairs? If yes, who? *
Are any able-bodied household members willing to assist in repairs? If no, why? *
Does anyone in the home live with a disability? If yes, explain. *
Please list the repairs needed? Foundation/siding/floors/insulation/weatherization/exterior walls/interior walls/roof/ceiling/windows/doors/bathroom/electrical/plumbing/porch/steps/ramp/handrails/other *
Names listed on the Property Deed *
Is the home listed in a life estate? *
Number of years homeowner has lived at this address *
Has the property been cited for any building or health code violations? If yes, please explain. *
Will the home be sold within the next 5 years? *
Home owners insurance company? *
Home Type *
House/Condo/townhome/mobile/manufactured
Year built? *
Is there a mortgage on the home? Name of mortgage company? *
Has this home been applied for in the past? *
Has Rebuilding Together done work on this home before? What was done and when? *
How did you learn about this program? *
Have any household members been convicted of a crime? *
Do you qualify for homestead tax credit or property tax rebate? *
Please list special circumstances regarding expenses within your household, such as home health care, hospital costs, medication expenses, etc. *
Please list the names of any members of the household who are unemployed (do not include children or elderly). *
Are there any renters residing in the home? If yes, how many? *
Income Source #1 *

Income Source Gross Monthly Income $
Income Source #2 *

Income Source Gross Monthly Income $
Income Source #3 *

Income Source Gross Monthly Income $
Income Source #4 *

Income Source Gross Monthly Income $
Income Source #5 *

Income Source Gross Monthly Income $
Household asset description and cash value and monthly Income from Asset *
Signature of Applicant *

First Name Last Name
Should be Empty: