Critical Home Repair Form

Applicant Information
Applicant Name:

First NameLast Name
Applicant's Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Applicant's Email:
example@example.com
Applicant's Social Security Number:
Applicant's Date of Birth:

MonthDayYear
Date
Has the applicant used any other names or social security numbers?
Please list any additional names or social security numbers used by the applicant, along with the years they were changed:
Is the applicant a US veteran?
Is the applicant disabled?
Does the applicant have any felony or misdemeanor criminal convictions, guilty pleas or pleas of no contest, deferred prosecutions, prayers for judgement, or pending charges (including minor traffic violations)?
Please list. Provide dates, courts of jurisdiction, counties/parishes, and sates:

Is the applicant's home located in Mecklenburg County?
Homes must be in Mecklenburg County AND have a zip code of 28105 or 28227 to be elligibile for our Critical Home Repair program.
Applicant Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Has the applicant lived at their current address for 2 years or longer?
Applicants must have lived at their current address for at least two years to qualify for the program.

Is there a co-applicant?

Are there additional household members? (including children)

Identification and Proof of Insurance
Copy of Applicant's Driver's License or State ID:

Cancelof
Copy of Co-Applicant's Driver's License or State ID:

Cancelof
Copy of Applicant's Current Homeowner's Insurance:

Cancelof
Copies of Additional Household Member's Drivers Licenses or State ID's (over the age of 18):

Cancelof

Household Income
List all sources of current monthly income for ALL HOUSEHOLDS MEMBERS, such as job compensation, Social Security, SSI (disability), child support, kinship care benefits, unemployment compensation, KTAP, TANF, or income earned from seasonal work:
Applicant Income Information
Co-Applicant Income Information
Additional Household Members Income Information
Total Monthly Household Income
Total Yearly Household Income

Household Assets
Please list the values of any of the following assets, if applicable:
Checking Accounts:
If you do not have one, please list $0.00
Financial Institution
Is this account jointly owned?
Name on Account
Savings Accounts:
Financial Institution
Is this account jointly owned?
Name on Account
Certificates of Deposit:
Stocks/Bonds/Mutual Funds:
Money Market Accounts:
Rental Properties:
Other Asset:
Describe Other Asset
Other Asset:
Describe Other Asset
Total Household Assets

Income Documentation
Applicant's Income Documentation:

Include any and all sources of income (check stubs, social security, disability, etc.)
Cancelof
Applicant's Most Recent Bank Statement:

Cancelof
Co-Applicant's Income Documentation:

Include any and all sources of income (check stubs, social security, disability, etc.)
Cancelof
Additional Household Members over the age of 18's Income Documentation:

Include any and all sources of income (check stubs, social security, disability, etc.)
Cancelof

Household Expenses
Please list your monthly expenses for the following bills:
Cable:
Car Loan:
Childcare:
Credit Cards:
Gas:
Electricity:
Healthcare:
Homeowner's Insurance:
Mortgage:
Phone/Internet:
Transportation:
Water & Sewer:
Other:
Other:
Other:
Other:
Total Monthly Household Expenses

Certification
Warning: Any false statements made knowingly and willfully may subject the applicant to forfeiture of further consideration for financial assistance.

PENALTY FOR FALSE OR FRAUDULENT STATEMENT: U.S.C. Title 18, Section 1001provides: “Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly or willfully falsifies … or makes any false, fictitious or fraudulent statements or representation, makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statements entry, shall be fined not more than $10,000 or imprisoned not more than five years or both”.
Certification
Applicant's Signature:
Date

MonthDayYear
Date
Co-Applicant's Signature:
Date

MonthDayYear
Date

Background Authorization
Please be advised that as part of our procedure for determining your eligibility to partner with Greater Matthews Habitat for Humanity ("Habitat"), we may obtain and consider criminal records, credit reports, driving records, consumer reports, and other background checks regarding you. Since Habitat may use consumer reporting agencies to provide the company such reports, Habitat is providing you with this notice and authorization form in order to comply with the Fair Credit Reporting Act.
Authorization to Conduct and Consider Background Checks

I hereby authorize Habitat to obtain consumer reports and investigate consumer reports on me and to consider such reports when making decisions regarding my partnership with Habitat. Such reports may include, but are not limited to information regarding my criminal record, driving record, credit, employment history and performance and other investigative reports. I understand that the agencies from which such reports may be sought may include, without limitation, criminal record search agencies, consumer information/credit bureaus and the like. I also understand that this authorization, in original or copy form authorizes Habitat to obtain and consider such reports regarding me any time when considering my potential or continued engagement with Habitat, both now and in the future.
Certification of Information Submitted to Habitat

I acknowledge that I have read the information contained on this form carefully. I also certify that all of the information provided by me on the attached data sheet(s) and on my application submitted to Habitat (and any attachments to them) were and are true and complete to the best of my knowledge. I further understand that any omission to the factor false or misleading information given on the data sheet(s) or on my application submitted to Habitat (and any attachments to them) may result in the withdrawal of my application and termination of my partnership with Habitat.
General Release

I I also release Habitat and its officers, directors, employees, other agents and all other persons, employers, businesses, schools, consumer information agencies, record search firms and other entities of and from any and all potential liability arising from inquiries by Habitat and its agents concerning the background checks described above and/or the compilation or use of such information and reports regarding me.
Authorization
Applicant's Signature:
Date

MonthDayYear
Date
Co-Applicant's Signature:
Date

MonthDayYear
Date
Should be Empty:

Critical Home Repair Form

Repair Requests

Applicant Information

Co-Applicant Information

Additional Household Member Information

Identification and Proof of Insurance

Household Income

Household Assets

Income Documentation

Household Expenses

Certification

Background Authorization