UAW-Ford Labor Management Committees Trust Fund Wheelchair Ramp Application •

UAW-Ford Labor Management Committees Trust Fund

Wheelchair Ramp Application

The UAW-Ford Community Outreach Committee has a history of providing wheelchair accessible ramps to those who reside in the communities where we live and work. UAW-Ford continues to recognize the need in our communities and is honored to provide this free service to those who qualify. To be considered, please fill out and submit the required registration form and appropriate documentation.

Applicant's Information

First Name*

Last Name*

Street Address*

City*

State*

Zip code*

Cross Streets (if applicable)

Phone Number*

Area CodePhone Number

What is your current affiliation? Please choose one.

To your knowledge, what is the nearest Ford location? Please choose one.

E-mail

Does the Applicant own this home?*

YesNo

If No, list full name of property owner:

If renting, has the property owner approved ramp install/tear-out? (Approval letter must be submitted)*

YesNo

Are there any Homeowners Association (HOA) restrictions?*

YesNo

If yes, please describe restrictions:

Is HOA approval needed?*

YesNo

Pets in household? (if yes pets must be secured during construction)*

YesNo

Property Information

Does the property currently have a ramp?*

YesNo

Does it need a tear-out?*

YesNo

Where is the ramp needed?*

Front of homeBack of homeSide of homeAttached garage

Number of people living in the home?*

Please Describe the disability or limitations of the residents living in this home*

Please Describe the circumstances preventing you from providing the ramp on your own.*

Name of person receiving the wheelchair ramp*

Please attach required documents (i.e. identification, proof of household income (see Household Member Income Worksheet below), address, prescription for ramp, building permit, landlord approval (if applicable), HOA approval, (if applicable)*

Select File

Property Owner Checklist for Ramp Request

I have filled in all the blanks on the ramp application?*

YesNo

I have a recent doctor's prescription stating my diagnosis and the need for a ramp?*

YesNo

I have completed and signed the household income worksheet for all persons living in my home and included proof of income, such as a recent tax return or Social Security benefits letter. If a household member has no income, write zero (0) on the appropriate income line. Please DO NOT send anything with a full Social Security number on it.*

YesNo

I have signed the home access and liability release form?*

YesNo

I have applied and received a building permit?*

YesNo

I have submitted recent proof of address. (In the form of ID, driver's license or utility bill)*

YesNo

Home Access and Release of Liability Agreement

This release is by and between the undersigned and the UAW-Ford Labor Management Committees Trust Fund ("Trust"). The undersigned acknowledges that he/she has voluntarily requested the Trust to construct a wheelchair ramp on the undersigned's premises and will provide all necessary access to the premises.

In consideration of the Trust's construction, the undersigned, on behalf of himself or herself and all occupants of the residence, and on behalf of his or her heirs, successors, executors, and administrators (collectively, the "undersigned") agrees that the undersigned will hold the Trust and its affiliated organizations (including the Ford Motor Company and the United Auto Workers International Union) and any of the Trust's directors, officers, employees, agents, volunteers, or contractors (collectively, "Trust and its affiliates and/or partner organizations") harmless against all claims, demands, and liability for any loss, injury or damage, or other casualty to persons or property, whether to the undersigned or third persons to the property, resulting from negligence or other acts, howsoever caused, by the Trust and its affiliates and/or partner organizations, relating in any way to the ramp, its construction, use or otherwise.

The undersigned assumes all risk and liability from the use of the wheelchair ramp built for him/her by the Trust, whether used alone or in combination with other equipment. Wheelchair ramps built for Trust clients are the property of the property-owner and it is the responsibility of the client and/or family to inform the agency when the ramp is no longer needed. If stairs must be removed and/or dismantled to accommodate the ramp, the Trust is not responsible for replacement of said stairs. The upkeep, repair and maintenance of the ramp is not the responsibility of the Trust.

THE TRUST AND IT'S AFFILIATES AND/OR PARTNER ORGANIZATIONS MAKE NO REPRESENTATION OR WARRANTY OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING WITHOUT LIMITATIONS, WARRANTIES OR MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE, REGARDING OR ARISING OUT OF THE CONSTRUCTION AND USE OF THE WHEELCHAIR RAMP. THERE ARE NO ORAL AGREEMENTS OR WARRANTS OUTSIDE OF THIS DOCUMENT.

The undersigned consent to the unrestricted use by the Trust and of any persons authorized by them of any photographs, interviews, videotapes, or similar visual or auditory recording of me or my home to promote the ramp project.

The undersigned has carefully read this release and fully understands its contents. The undersigned is aware that this is a release of liability and a contract between the undersigned and the Trust and its affiliates and/or partner organizations. The undersigned has signed this release of the undersigned's own free will.

Signature (use mouse to sign application. Should be signed by both applicant and homeowner (who may or may not be the same person)

Signature (use mouse to sign application)*

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Household Member Income Worksheet: Please list each Household Member's Income on this worksheet and attach documentation that substantiates the information for each member of the household. (Upload documentation in the Select File area above)*

	NAME	RELATIONSHIP	TYPE OF INCOME	MONTHLY	ANNUAL
1
2
3
4
5
6
7

Calculate totals from Household Member Income Worksheet and place them here:*

	ALL HOUSEHOLD MEMBERS
TOTAL MONTHLY INCOME
TOTAL ANNUAL INCOME

I certify to the best of my knowledge and belief that the information above is accurate. (Please sign and date (use mouse to sign application.) Should be signed by both applicant and homeowner(who may or may not be the same person).*

Clear