Owner Occupied Rehab Application

Name

First NameLast Name

Birthdate

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Do you own your home?

Do you have Homeowner's Insurance?

Who is your Homeowner's Insurance Provider?

Are your property taxes current?

How many people live in your household?

Home Occupants

Family Employment and Income

Do you receive pay statements/pay stubs?

Do you receive income from a home-based business or self-employment?

Do you receive income from annuities, insurance policies, retirement funds, pensions, disability or death benefits and other similar type of periodic payments?

Do you receive unemployment, disability compensation, workers’ compensation or severance pay?

Do you receive welfare assistance of any kind?

Do you receive alimony or child support?

Does anyone in your household receive regular or special pay from a branch of the Armed Forces?

Do you receive recurring monetary contributions or gifts from someone who does not live in your home?

*If you answered yes to any of the question above regarding your income sources, please provide documentation to verify that income in the required attachments section below

Total Collective Household Monthy Income

Please give a detailed description of the repairs you require. Describe the work that needs to be done, reasons the repairs are necessary, and the desired end result.

Are you able to provide some of the labor necessary to complete your repair project? (you, family, friends, neighbors, etc.)

Are you able to offer any other support to Habitat volunteers while they work on your repair projects? (water, restrooms, etc.)

How long do you plan to stay in this home?

Please indicate whether any of the following apply to you or a member of your household.

I certify that the information provided on this application is accurate. I agree to offer my assistance and support to Habitat and its representatives, who complete my home repair project, to the best of my ability. I understand that the labor for this program may be completed by unpaid volunteers. Habitat has assured me that repair volunteers will be properly trained and supervised by a member of Habitat’s construction staff. I also understand that the Owner Occupied Rehabilitation Programs offers no warranties, expressed or implied, regarding any of the materials used or work completed during this project. I hereby release Owner Occupied Rehabilitation, Mon Valley Habitat for Humanity and all volunteers and staff associated with this program form any liability whatsoever.

I understand that by filing this application, I am Authorizing Habitat for Humanity to evaluate my actual need for the Habitat owner occupied rehab program. I understand that the evaluation will include personal visits and income verification. I also understand that program requirements—such as my home’s location and demographic considerations—will be taken into account during the selection process. I have answered all of the 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 for the program, I may be disqualified from the program. The original or a copy of this application will be retained by Habitat for Humanity even if the application is not approved. I also understand that Habitat for Humanity screens all applicant families to determine if they are on the sex offender registry. By completing this application, I am submitting myself to such an inquiry. I further understand that by completing this application, I am submitting myself to a criminal background check.

Most recent property tax bill or statement. This document must show the current tax value of the home and property, your name and physical address, recent payments and any balance due on the property.

If you are currently making payments on a mortgage for the home in need of repair, please attach the most recent copy of your mortgage statement. Again, this must show the name and physical address of the homeowner and the balance due on the mortgage.

Documentation for all salaries/paychecks received by occupants of the home in need of repair (paystubs, income tax returns, etc). These documents must include name of the income source, name of the recipient, and the amount received. If you receive pay statements, please provide the three most recent below.

*Documentation of any additional or supplemental income received.

Documentation of current Homeowner’s Insurance.

Please provide copies of your tax returns for the past 2 years.

Additional pages needed to describe the repairs you are requesting. Also, if possible, attach photographs of the repairs you are requesting.

Owner Occupied Rehab Application

Homeowner Agreement

Required Attachments