The Impact Project Participant Application

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

Rows	Name	Age	Employment Status (FT, PT, Retired, Disabled, Other)
Applicant
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)
*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.

Type of residence*
Do you pay a Mortgage/Lien/Judgement/Home Equity Line of Credit on your home/property?*
:
If yes, please explain your situation.
Is your Mortgage/Lien/Judgement/Home Equity Line of Credit on your home/property paid off?*
:
Are your Property, School, & Village (if applicable) taxes current?*

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

Roof Repair/ReplacementFurnace Repair/ReplacementElectrical PanelSepticHandicap ShowerHandicap Ramp (main entrance only)PlumbingHot Water Heater Repair/ReplacementOther
If Other (above) please explain - The Impact Project is not able to work on wells or foundation issues.
How long have you been needing the repairs you've indicated on your application?*
Are there any special circumstances we should be aware of (financial, health, etc.) that you would like to share?*
What steps have you taken, if any, to temporarily fix your situation?
In what time frame would you like to have these repairs done?
Is there any additional information you'd like us to know?

Have you applied with The Impact Project before?*
If yes (above) please explain:
Are you aware of other organizations that could help you?*
If Yes (above) which organizations and have you applied for help with them?
Do you attend a local church in your area?*
If Yes (above), please share church name and location (town) they are located in:
Are you or anyone in your household a veteran?*
If Yes (above) which branch was served:

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

Rows	Your Income (monthly)	Others in Household income (monthly)
Work = Net Pay
Unemployment
Pension/CD/Annuity/IRA/ROTH
SSI/SSD/SSA
HEAP
Public Assistance/TANF
SNAP/EBT Benefits
Child Support
Alimony/Palimony
Other

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

Rows	Average Monthly Expense
Rent/Mortgage (including escrow)
Property/School/Village Taxes
Homeowners Insurance
Heat
Electric
Water
Phone/Internet
Household Expenses/ Furnishings
Repair/Improvements
Car Maintenance
Car Insurance
Gasoline
Other Transportation (bus/taxi/parking)
Groceries (Including SNAP)
Paper/Cleaning Supplies
Meals Out
Clothing
Medical/Dental/Vision
Life Insurance
Education
Gifts
Donations
Cable/Satellite TV
Entertainment (videos/music/sports/hobbies/going out)
Child Care
Vacation
Grooming Supplies
Haircuts/Laundry
Pets
Other
Other

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.
At this time, we need a copy of the documents listed below. For your protection, please send the documents to our office by mail or drop off at our office. You have 30 days from the time you submit your online application to provide this information to us or your application with be closed. Our mailing address is: The Impact Project, 4 Clinton Street, Greene, NY 13778. If you have any questions please call: 607-656-9499.
Terms
The information on this application is true and correct to the best of my knowledge.*

I Agree
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Participant Application