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 NameLast Name
Owner Name*

First NameLast Name
Property Address - Note: property must be within 10 miles of Bismarck, ND*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
Best way to reach you?*
Email or by phone
Best time to reach you?*
Relationship to Applicant*
Emergency Contact*
Name and phone #
Total number of Adults Living in the Home (18+)*
Total number of children under 18 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.*
Does anyone in the home live with a disability? If yes, explain.*
Are any able-bodied household members willing to assist in repairs? If yes, who?*
Are any able-bodied household members NOT willing to assist in repairs? If not, why?*
Is anyone in the home active military or a veteran? If so, what branch?*
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 there a mortgage on the home? Name of mortgage company?*
Number of years homeowner has lived at this address*
Home Type*
House/Condo/townhome/mobile/manufactured
Year built?*
Home owners insurance company?*
*Having home insurance is a requirement to be selected
Is the home listed in a life estate?*
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?*
Has this home been applied for in the past?*
Has Rebuilding Together done work on this home before? What was done and when?*
Do you qualify for homestead tax credit or property tax rebate?*
Have any household members been convicted of a crime?*
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?*
How did you learn about this program?*
Please list special circumstances regarding expenses within your household, such as home health care, hospital costs, medication expenses, etc.*
Income Source #1*

Income SourceGross Monthly Income $
Income Source #2

Income SourceGross Monthly Income $
Income Source #3

Income SourceGross Monthly Income $
Income Source #4

Income SourceGross Monthly Income $
Income Source #5

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

First NameLast Name
Should be Empty: