The Impact Project Participant Application

Participant Application
Full Name*

First NameLast Name
Primary Phone Number*

Area CodePhone Number
Other Phone Number

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
E-mail*
Referred by
*The Impact Project is not able to work on rental properties. Exceptions for trailer park lot rentals where the applicant is the owner of the home. Park owner permission may be required for outdoor work.

For each person living in the household, including yourself, please enter details below:*

	Name	Age	Employment Status (FT, PT, Retired, Disabled, Other)
Member 1
Member 2
Member 3
Member 4
Member 5
Member 6
Member 7
Member 8

Any additional members of the household unable to list above, please provide name, age and employment status below (FT, PT, Retired, Disabled, other)
Are you or anyone in your household a veteran?*
If Yes (above) indicate branch served in:

Need/assistance information
What assistance are you in need of? (Can select more than one)*

RoofFurnaceElectricalSepticHandicap RampHot Water HeaterPlumbingOther
If Other (above) please explain - The Impact Project is not able to work on wells or foundation issues.
How long has your requested need been an item in need of repair?*
Are there any special circumstances we should be aware of (financial, health, etc.)?*

Household Income Form MONTHLY (if not applicable, please enter a 0 - zero)*

	Your Income (monthly)	Others in Household income (monthly)
Work = Net Pay
Unemployment
Pension
SSI/SSD/SSA
Public Assistance / TANF
SNAP
Child Support
Alimony/Palimony
Other

Household Expenses - Average MONTHLY (if not applicable, please enter a 0 - zero)*

	Average Monthly Expense
Rent/Mortgage
Heat
Electric
Water
Phone/Internet
Property taxes
Household Expenses/ Furnishings
Repair/ Improvements
Home Insurance
Car Maintenance
Car Insurance
Gasoline
Other Transportation
Groceries
Paper/Cleaning Supplies
Meals Out
Clothing
Medical/Dental/Vision
Education
Life Insurance
Gifts
Donations
Entertainment
Child Care
Vacation
Grooming Supplies
Haircuts/Laundry
Pets
Cable/Satellite TV

Debts - credit cards, home equity loans, car payments, student loan, medical debt (if no debts, enter 0 - zero in first field)*

Additional debts, please enter below.
Attach IRS 1040 Form

Browse Files
**required for everyone in household who files Cancelof
Attach Complete (all pages) Bank Statements for Everyone In The Household*

Browse Files

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Attach Statements of Income

Browse Files
**required only for income which does not appear on bank statement Cancelof
Any other supporting documents - please no drivers license or social security cards

Browse Files

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Final Submit
Terms
The information on this application is true and correct to the best of my knowledge.*

I Agree
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Participant Application