Critical Home Repair Application

How did you hear about this program?

Applicant's Full Name*

First NameMiddle NameLast Name

SSN*

Date of Birth*

Date

Co-Applicant's Full Name

First NameLast Name

Co-Applicant's SSN

Co-Applicant's Date of Birth

Date

Home Address

Street Address

Street Address Line 2

CityState

Zip Code

Neighborhood Name (if known)

Number of Years at Address

Phone Number

Please enter a valid phone number.

Marital Status

E-mail

example@example.com

Education Level

List ALL people that live in home (including applicant)

	Name	Date of Birth	Relationship to Applicant	Gross Monthly Income (before taxes)
1.
2.
3.
4.

List ALL people that live in home (including applicant)

Is anyone in the home a veteran?

YesNo

Is anyone in the home disabled?

YesNo

If yes, indicate the type of disability (check all that apply, please describe if "other")

Is translation needed?

YesNo

If yes, what language?

Do you have pets?

YesNo

If yes, what kind and how many?

Do you own the home where work is to be done?

YesNo

Do you live in the home where work is to be done?

YesNo

Does anyone else own the home/on the deed?

YesNo

If yes, name/relationship:

Are you making loan payments on your home?

YesNo

If yes, what is your monthly payment?

Are your loan payments current?

YesNo

Do you have homeowner's insurance?

YesNo

Name of CURRENT Employer

Type of business

Business Phone

Please enter a valid phone number.

Address of CURRENT Employer

Street Address

Street Address Line 2

CityState

Zip Code

Start Date

Date

Gross Monthly Income ($)

Please include last 3 months of pay stubs, SSI/Disability Beneficiary Letter or Pension/401K Retirement Account Statement.

Name of PREVIOUS Employer

Type of business

Business Phone

Please enter a valid phone number.

Address of PREVIOUS Employer

Street Address

Street Address Line 2

CityState

Zip Code

Start Date

Date

Gross Monthly Income ($)

Income

	Applicant	Others in Household	Total
Wages
Allimony
Child Support
Food Assistance
Cash Assistance
Social Security
SSI
Disability
VA Benefit
Other
Total

Expenses

	Applicant	Others in Household	Total
Mortgage
Car Payment
Credit Cards
Child Support
Student Loans
Utilities
Home Insurance
Other
Other
Other
Total

Bank, Savings & Loan, or Credit Union Information

	Name	Address	Account	Balance
1.
2.
3.
4.

Upload Bank & Loan Statements and other assets

Which type most resembles the size of your house?

1 Story1.5 Story2 Story2.5 Story

House Exterior: Siding

House Exterior: Trim

WoodVinylMetal

Garage Exterior: Siding

Garage Exterior: Trim

WoodVinylMetal

Briefly describe the type of work you would like done on your house. Attach a separate piece of paper if there is not enough space to list all the repairs. Remember the items listed below will be considered for repair, but the final decision on what work can be done with our time and financial resources will be made at the discretion of Iowa Heartland Habitat for Humanity.

Requested Repairs

	Needed	Description
Accessibility Modifications: Ex: wheelchair ramp, grab rails
Roofing Repairs: Identify where roof leaks
Exterior Painting
Doors and Windows: Describe repairs required
Heating/Cooling Repairs: Describe problems
Plumbing: Identify leaks/problems
Other

File Upload

Please write a brief explanation of why you are in need of home repair services, and how it will help you.

Have you applied to this program in the past?

YesNo

Will you return phone calls and submit paperwork in a timely manner?

YesNo

Will you contribute a combination of sweat equity hours and payment to help fulfill Habitat'smission?

YesNo

Will you be at your home or make your home available while work is being completed on your house?

YesNo

Will you fully prepare the site in advance of volunteers and contractors? This can include temporarily removing items from your yard and the sides of your house, relocating outdoor pets, mowing the lawn and eliminating weeds, providing access to your bathroom and making house accessible.

YesNo

Will you be present and engaged with volunteers and contractors working on your home as often as possible?

YesNo

Will you work with a team with people you don't know, including volunteers and staff? If you are not able to help with construction, will you find other ways to support volunteers?

YesNo

I certify that the information on this application is accurate; that I own and reside in the property at the address given on this application; and that I have no present intention to move or offer my home for sale for at least 5 years. I confirm that any physically able persons residing in my home or visiting for the project day will work alongside the IHHFH volunteers. I confirm that except for the conditions above, the exterior of my home is a safe place for volunteers. I understand that by submitting this application, I am authorizing Iowa Heartland Habitat for Humanity to evaluate my need for home repairs, my ability to pay a percentage of project costs and my willingness to be a partner family. I understand that the evaluation will include a home assessment and income verification. I understand that my project may be subject to a 5 year deed restriction. I have answered all questions on this application truthfully. I understand that if I have not answered the questions truthfully, my application may be denied, and that even if I have already been selected to be eligible to receive Home Repairs services, I may be disqualified from the program. The original or a copy of this application will be retained by Iowa Heartland Habitat for Humanity even if the application is not approved.

If this application is created as (or converted into) an "electronic application," I consent to the use of "electronic records" and "electronic signatures" as the terms are defined in and governed by applicable federal and/or state electronic transaction laws. I intend to sign and have signed this application either using my: (a) electronic signature or (b) a written signature and agree that if a paper version of this application is converted into an electronic application, the application will be an electronic record, and the representation of my written signature on this application will be my binding electronic signature.

Applicant's Signature*

Date

Month - Day - Year

Applicant's Name (Printed)

First NameLast Name

Co-Applicant's Signature

Date

Month - Day - Year

Co-Applicant's Name (Printed)

First NameLast Name

Do you wish to furnish this information?

YesNo

Race (applicant may select more than one racial designation)

Ethnicity

Hispanic or LatinoNon-Hispanic or Latino

Sex

FemaleMale

Birthdate

Date

Marital Status

MarriedSeparatedUnmarried (single, divorced, widowed)

Do you wish to furnish this information?

YesNo

Race (applicant may select more than one racial designation)

Ethnicity

Hispanic or LatinoNon-Hispanic or Latino

Sex

FemaleMale

Birthdate

Date

Marital Status

MarriedSeparatedUnmarried (single, divorced, widowed)

HOME REPAIR PROGRAM APPLICATION

Section 1: Homeowner Information

Section 2: Special Circumstances

Section 3: Mortgage Information

Section 4: Employment Information

If working at current job less that one year, complete the following information.

Section 5: Monthly Income and Expenses

Section 6: Assets

Section 7: House Information/Repair Requests

Section 8: Personal Statement

Section 9: Willingness to Partner

Section 10: Applicant Agreement

Section 11: Information for Government Monitoring Purposes

Applicant

Co-Applicant