APPLICATION FOR FREE HOME REPAIRS

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1 APPLICATION FOR FREE HOME REPAIRS P.O. Box Chicago, IL fax This application is the first step of the Rebuilding Together Metro Chicago selection process. If your application meets the necessary requirements, an in-home visit will be scheduled to obtain additional information for a final determination of eligibility. If your home is selected by a program sponsor, all repairs will be performed on National Rebuilding Day, Saturday, April 25, 2015 by a group of approximately 30 of that sponsor s volunteers. All able-bodied persons living in your home are required to work alongside sponsor volunteers. Part A: Homeowner s Information: 1. Homeowner s Name: Age: Title First Name Middle Initial Last Name 2. Spouse- or Co-owner- : Age: Title First Name Middle Initial Last Name 3. Address: Street Address Unit # City Postal Zip Code 4. Home Phone: Homeowner Work Phone: Homeowner Cell Phone: Address: 5. Additional Phone Contact (neighbor or relative, if we can t reach you): Name Phone Number Relationship to Homeowner 6. Homeowner Birth Date: Spouse/Co-Owner Birth Date: 7. Homeowner Gender: Male Female 8. Homeowner Marital Status: Single Married Divorced Widowed 9. Race/Ethnicity (optional): African American Asian American Hispanic Latino Native American Non Hispanic White Other 9. Is the Homeowner disabled? If yes, please list your disability: 10. Is another member of your household disabled? If yes, family member s name: Disability: 11. Do you have a social worker/care manager/home healthcare provider? Page 1

2 Part B: Homeowner s Annual Income Information: Indicate whether you receive income from the sources listed below by marking the Yes box, and enter the corresponding annual income received from that source in the Homeowner Income or Co-owner or Spouse Income box. Homeowner Co-owner or SOURCES OF INCOME YES Income Spouse Income Employment wages? $ $ Office Use Only Self-employment wages? $ $ Social Security benefits? $ $ Disability income? $ $ Pension income? $ $ Rental income? $ $ SSI/AABD income? $ $ Unemployment compensation? $ $ Child support? $ $ AFDC income? $ $ Additional income not listed above? (Please describe.) Part C: TOTAL ANNUAL INCOME Homeowner Employer Employer Information: Employer: Address: Work Phone: Position: Retired: $ $ $ $ Co-owner or Spouse Employer Employer: Address: Work Phone: Position: Retired: Page 2

3 Part D: Veteran Information: 1. Is the homeowner a veteran of the U.S. armed forces? 2. Is another member of your household a veteran of the U.S. armed forces? 3. Are you the widow or widower of a veteran of the U.S. armed forces? 4. Is any member of your household currently serving in the U.S. armed forces? For all veterans in your family, please complete the following information: (Attach additional pages if necessary) Family member s name: Branch of Military: Years of Service: Locations of Deployment: Special Distinctions or Awards Received: Part E: Mortgage Information: 1. Is there a mortgage on this property? 2. Who is listed as the owner/s on your mortgage document? 3. Do you currently have a reverse mortgage? 4. Are you currently behind in your mortgage payments? If yes, what date was your last payment made? 5. Are you currently in danger of foreclosure? 6. Are you currently working with a bank or foreclosure specialist to prevent foreclosure? If yes, what company? If yes, what is your current status? 7. Do you have homeowner s insurance? 8. Do you plan to sell your home within the next 2-3 years? Page 3

4 Part F: Property Information: 1. What is the approximate age of your home? 2. How long have you lived in your home? 3. Is your home a single family home? 4. Does your home have more than one unit or apartment? If yes, in which unit do you (homeowner) reside? 5. Are there rental units? If yes, number of rental units? If yes, how many rental units are currently occupied? If yes, what is the current total of the rental income you receive? $ 6. Do you own any other property/buildings in addition to the home you occupy? If yes, please list address(es): Part G: Needed Repairs: The core mission of Rebuilding Together * Metro Chicago is to accomplish repairs that make homes warm, safe and dry. If you are chosen to receive free home repairs by Rebuilding Together * Metro Chicago, what specific home repairs would be of most assistance to you? Do you have handrails on all your stairways and are they secure: Do you have difficulty getting in and out of the shower or bathtub? Do you have difficulty getting on and off of the toilet? Do you have working smoke detector? Are any of your appliances broken? If yes, which? Stove Refrigerator Washer Dryer Do you have leaks? If yes, where? Roof Baement Pipes Faucet(s) Page 4

5 Do you have sparking at your electrical outlets? Does your hot water heater work? How do you currently heat your home? Boiler Furnace Space Heater Oven Do you have a pest or rodent problem? Do you often use your backyard or garden? When was the last time the interior of your homes was painted? Would you benefit from assistance removing unwanted stored items in your home or garage? If yes, please describe items: Would you be comfortable with a team of 25 volunteers in your homes at one time? Please explain how receiving free home repairs would help you and your family. If your home is selected for the program, what special, interesting facts about you or your family would you like to share with your sponsor? How did you hear about our program? (Check all that apply.) Church Alderman City Department Mail Friend Other Have you ever received assistance from Rebuilding Together * Metro Chicago or Christmas in April before? If yes, what year? Page 5

6 Part H: Household Information: 1. List ALL persons living in your home including children and yourself. For every person living in the home list the name, age, relationship to homeowner, and how much, if anything, this person pays in rent. If more than 8 people live in the house, use additional sheets. NAME AGE RELATIONSHIP RENTING? 1. Self Owner Including the homeowner, how many people reside in the home? a) Total number in household: b) Number of males: c) Number of females: d) Number of persons 60 or older: e) Number of children under 18: f) Number of disabled persons: 3. Are any of the people listed above moving out before April 2014? If yes, please list who: 4. Do you expect anyone else to move in before April 2014? If yes, please list who: Page 6

7 Part I: Additional Household Members Annual Income Information: 1. Does anyone over 18 years of age live with you (not including yourself and co-owner or spouse)? 2. If yes, list all persons 18 years of age or older currently living with the homeowner in the table below, regardless of employment status. If an adult member of your household receives income, enter the annual income they receive in the corresponding box in the column with their name. Make additional copies if needed. ADDITIONAL HOUSEHOLD MEMBER S NAME: Name: Name: Name: Name: Is this person currently enrolled in high school or university? Is this person paying rent? SOURCES OF INCOME Amount of Yearly Income Amount of Yearly Income Amount of Yearly Income Employment wages? $ $ $ $ Self-employment wages? $ $ $ $ Social Security benefits? $ $ $ $ Disability income? $ $ $ $ Pension income? $ $ $ $ Rental income? $ $ $ $ SSI/AABD income? $ $ $ $ Unemployment compensation? $ $ $ $ Child support? $ $ $ $ AFDC income? $ $ $ $ Additional income not listed above? (Please describe.) $ $ $ $ TOTAL ANNUAL INCOME $ $ $ $ Amount of Yearly Income Page 7

8 Part J: Disclosures: I affirm that I/we am/are the homeowner/s, and I reside full time at the address listed on the application. All owners must sign below. Attach additional pages if necessary. (Homeowner Signature) (Homeowner Print) (Date) (Co-owner Signature) (Co-Owner Print) (Date) Have you or any immediate family member worked for or been affiliated with Rebuilding Together * Metro Chicago, the Governments of the City of Chicago, Cook County, or the village in which you reside? If yes, please list person s name, position title and dates worked below: Attach additional pages if necessary. Name: Title: Dates: Name: Title: Dates: Part K: Certification: I certify that the above information is true and correct to the best of my knowledge. I authorize Rebuilding Together * Metro Chicago to check any references necessary to complete the processing of this application for the purpose of receiving free housing repair. The Homeowner(s) grant Rebuilding Together permission to take still and moving photographs, including video pictures of the Home and to use such photographs to publicize, in any manner Rebuilding Together deems appropriate, Rebuilding Together s program. I understand that providing false or incomplete information may make me ineligible or result in disqualification from the program. I also understand that any information received will be kept confidential and will be used strictly for the purpose of determining my eligibility to receive free home repair through Rebuilding Together * Metro Chicago and to recruit sponsors. (Homeowner Signature) (Co-owner or Spouse Signature) (Date) (Date) Mail Mail Completed completed Application application To: to: Rebuilding Together Together ** Metro Metro Chicago PO Box Chicago, IL Page 8

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