Application:
Name:
Age:
Address:
City:
Zip:
Phone:
Names
and ages of all persons living in the home:
Do
you own your home?
How
long have you lived in the current address?
Have
you applied to Rebuilding Together in the
past?
When?
List
sources of all income per month (i.e. Social Security, SSI, AFDC, VA Benefits,
interest/dividends, etc...)
Is
the homeowner or anyone else residing in the home disabled?
If
so, indicate special needs (wheelchair or walker, hearing-impaired, etc):
How
many children do you have living in the area?
Explain
why you or family members cannot do the repairs:
List
the most-necessary work needed in order to make your home safe, secure and
weatherproof. (Funds are limited and not all repairs can be made).
My
signature below indicates that the information provided above is accurate and
complete. I have read the information provided by Rebuilding Together of
Greater Green Bay and have a basic understanding of the program and its
process. I give rebuilding Together volunteers my permission to inspect my
home for purposes of home selection and/or repair.
Signature
of applicant __________________________________
Date
of application ____________________________________
If
this form is prepared by someone other than the homeowner, or if assistance is
give the homeowner, please complete the following:
Is the homeowner aware of this application?
Name
of person assisting with application:
Phone:
Agency:
rev.
03-15-07
Date received: _______________________
