General Repair Application

SUPPLEMENTARY DOCUMENT CHECKLIST
Please submit the following documents along with your home repair loan application. Note: Not all documents will be applicable for your situation. If you have questions or need assistance locating certain documents, please call (361) 573-2511 or email kemberley@goldencrescenthabitat.org . Applications are considered incomplete until all applicable documentation is submitted

SUPPLEMENTARY DOCUMENT CHECKLIST

Rows	Attached	N/A
Copies of photo for all persons in the household (ex: driver's license, passport)
Applicant Release Form (see attached) signed by applicant and co-applicant (if applicable)
If self-employed, provide the past two years. Tax returns
Most recent pay stubs from employer(s) from the last three (3) months
Most recent statements for checking and savings accounts for the last two (2) months
Proof of Social Security Benefits for retirement, disability, survivor and family (All pages are required of your most current award letter)
Proof of VA Benefit (Letter showing gross amount)
Most recent child support 12 months payment history
Most recent statement for retirement funds and other investments
Deed of home or proof of homeownership (if inherited please provide death certificate(s), probated will, gift deed, or affidavit of heirship)
Most current mortgage statement (if applicable)
Most current property tax receipt
Most current utility bill (2) months with homeowner name and address (electric or water)
Note from doctor explaining need if requesting ADA shower or ramp
DD Form 214 - Certificate of release or discharge from active duty
NGB-22 National Guard if applicable)

Copies of photo for all persons in the household (ex: driver’s license,passport)

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Applicant Release Form (see attached) signed by applicant and co-applicant(if applicable)

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If self-employed, need the past two yrs. Tax returns

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Most recent pay stubs from employer(s) from the last three (3) months

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Most recent statements for checking and savings accounts for the last two(2) months

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Proof of Social Security Benefits for retirement, disability, survivor and family(All pages are required of your most current award letter)

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Proof of VA Benefit (Letter showing gross amount)

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Most recent child support 12 months payment history

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Most recent statement for retirement funds and other investments

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Deed of home or proof of homeownership (if inherited please provide death certificate(s), probated will, gift deed, or affidavit of heirship)

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Most current mortgage statement (if applicable)

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Most current property tax receipt

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Most current utility bill (2) months with homeowner name and address(electric or water)

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DD Form 214 – Certificate of release or discharge from active duty

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NGB-22 National Guard if applicable)

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Golden Crescent Habitat for Humanity
Submit completed application to office online or by APPOINTMENT ONLY
Golden Crescent Habitat for Humanity
4103 N. Navarro St., Suite 200
Victoria, TX 77901
Email: kemberley@goldencrescenthabitat.org
Phone: (361) 573-2511
We are pledged to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtain housing because of race, color, religion, sex, handicap, familial status, or national origin.
HOME REPAIR APPLICATION
HOUSEHOLD INFORMATION
Applicant
Birth Date:

MonthDayYear
Date
Disabled? If yes please describe:
Describe here
Email:
example@example.com
Phone #:
Format: (000) 000-0000.
Co-Applicant (if applicable)
Birth Date:

MonthDayYear
Date
Disabled? If yes please describe:
Describe here:
example@example.com
Email:
example@example.com
Phone #:
Format: (000) 000-0000.
Did you or anyone in your household serve or is currently serving in the military

Other Household Residents

HOME INFORMATION
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
City:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Was the home built before 1978?
Are there other listed owners besides the applicant and co-applicant? Legal name(s) of additional owner(s): Please use back for additional information
Do you have a city and/or county citation? If yes, what is the service period? Please use back for additional information
Applicant must occupy the home as a primary residence. Do you expect to move within the next year? If yes, please list reason for moving: Please use back for additional information

SHARING PERSONAL INFORMATION
If your application is a more appropriate fit with other similar programs may we share it with?
(Initial) I give GCHFH my consent to share the information in this application with similar organizations.
Is there anyone you would like to authorize us to communicate with on your behalf regarding your project and information? (case worker, health navigator, friend, relative, etc.?
If yes, fill out next sections:
Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
Email:
example@example.com
(Initial) I give GCHFH my consent to share my application/project details with the person listed above.

HOMEOWNER ACKNOWLEDGEMENT
I certify that the facts set forth in this application are true and complete. I understand that I may be declined or removed from the program if the information provided is later determined to be untrue. I understand that GCHFH is verifying my credit record and screening all household members on the sex offender registry. I further understand that by completing this application, I am submitting myself and any household member over 18 years of age. I realize I have the right to dispute the information reported. I agree to all the above and sign this of my own free will.
Applicant Signature
Date

MonthDayYear
Date
Co-Applicant Signature
Date

MonthDayYear
Date

PHOTO/VIDEO RELEASE
Photographic Release: I do hereby grant and convey unto Habitat all right, title, and interest in any and all photographic images and video, audio, and electrical recordings made by Habitat during my Activities with Habitat, including but not limited to, the right to use such materials for any purpose and the right to any royalties, proceeds or other benefits derived from them. I understand that I will not have any ownership interest in or to such photographs, images and/or recordings, I have not been provided or promised any compensation, and I hereby waive any rights, privileges or claims based on any right, of publicity, ownership or any other rights arising, relating to or resulting from the photographs, images and/or recordings. I understand and agree that this paragraph also applies to my minor children who are volunteering.
Signature of Applicant:
Date

MonthDayYear
Date
Signature of Co-Applicant:
Date:

MonthDayYear
Date

FAMILY BIO
Please write a short family bio as it may be helpful in finding sponsors to help fund your project.
Should be Empty:

SUPPLEMENTARY DOCUMENT CHECKLIST