2022 RTNCF Safe at Home Application

1
What is your name?* This field is required.
First Name
Last Name
2
Contact InformationTell us how to reach you
Please enter your email address
Please enter your phone number
Alternate phone number (optional)
3
Address* This field is required.This is the physical address of the home
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Mailing Address (if different)This field is optional
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Is your home located in Levy County?* This field is required.Only addresses located in Levy County are eligible for this program
YESNO
6
Office use only: Verified in Levy County* This field is required.Only Levy County addresses are eligible for this program
YESNO
7
Are your property taxes current?* This field is required.Property taxes must paid through 2021 to be eligible for services.
YESNO
8
Are you the homeowner? (Sole or co-owner)* This field is required.For this program the applicant must be clearly listed on the deed of the home where services are requested.
YESNO
9
What describes the category of home modification or repairs needed? (select all that apply)* This field is required.The Safe at Home program prioritizes high-impact home modifications based on the interaction between the person, home environment, and functional activity.
Exterior Accessibility (difficulty to enter/exit home safely - ramp, handrails, pathway lighting or uneven pathways, etc.)
Interior Accessibility (railings, uneven floor surfaces, door adjustments, etc.)
Bathroom Modifications (to prevent falls - grab bars, raised toilets, tub cuts, nonskid strips for bathtub or shower floor, etc.)
Mobility Aid Accessibility (for maneuverability - chair lift/stair climber, pedestal sink to access bathroom facilities, widening doorways, etc.)
Other safety hazards (trip hazards, slippery surfaces, broken window pane(s), damaged entry door, etc.)
10
How many people are living in your home?* This field is required.Include anyone who stays in your home an average of 2+ nights a week within the past 6 months
11
Household Member(s) Information* This field is required.Please provide name, gender, ethnicity, age, and estimated monthly income for each resident in the household.
Name
Gender
Ethnicity
Age
Monthly Income
You
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3
4
5
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You
2
3
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Name
Gender
Ethnicity
Age
Monthly Income
Name
Gender
Ethnicity
Age
Monthly Income
Name
Gender
Ethnicity
Age
Monthly Income
Name
Gender
Ethnicity
Age
Monthly Income
Name
Gender
Ethnicity
Age
Monthly Income
Name
Gender
Ethnicity
Age
Monthly Income
Name
Gender
Ethnicity
Age
Monthly Income
Name
Gender
Ethnicity
Age
Monthly Income
Name
Gender
Ethnicity
Age
Monthly Income
Name
Gender
Ethnicity
Age
Monthly Income
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12
Copy of Identification (for ALL residents)* This field is required.Examples: Government issues ID/Driver's License, birth certificate, or social security card.
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Select files to upload
Max. file size: 10.6MB
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13
Proof of Income (ALL income for ALL residents)* This field is required.Examples: Most current Social Security or Disability annual benefit letter, 3 months of paycheck stubs or bank statements, retirement benefits summary, or income tax returns. If there is no household income, upload a document or photo stating such.
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Select files to upload
Max. file size: 10.6MB
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14
Proof of Veteran Status (if applicable)Examples: DD 214, Veteran ID card
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
15
I have read the information provided by Rebuilding Together North Central Florida (RTNCF) and understand the program and its processes.* This field is required.Additional information is on our website: rebuildingtogetherncf.org.
YESNO
16
I certify that I do not have the financial means to perform the repairs for which I am applying.* This field is required.
YESNO
17
I understand that I may be asked to provide additional documentation to verify my answers.* This field is required.
YESNO
18
I authorize investigation and verification of all information provided, including a personal background check, if necessary, for my involvement with RTNCF.* This field is required.
YESNO
19
I give permission for RTNCF representatives and volunteers to inspect my home for purposes of home selection and/or repair.* This field is required.
YESNO
20
I understand that there is no cost to the homeowner for repairs done by RTNCF.* This field is required.
YESNO
21
Signature* This field is required.My signature indicates that all of the above statements and information provided are accurate and complete.
Clear
22
Please, rate this application on how easy it was to understand and complete. Note, your response will not affect your chance to receive assistance.
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