AC for Seniors/Cool Down St. Louis- Jefferson County Air Conditioner Application

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1 Dear Homeowner, AC for Seniors/Cool Down St. Louis- Jefferson County Air Conditioner Application 3875 Plass Road, Bldg. A Phone: Dennis Murphy x106 Phone: Tom Rojas x112 Fax: Website: Each summer when funds are available, Hammers of Hope conducts two initiatives, AC for Seniors and Cool Down St. Louis-Jefferson County, to give window air conditioning units to low income families, seniors, and persons with disabilities to provide a safe place of heat relief in at least one room of their residence. Hammers of Hope is a nonprofit volunteer program that brings volunteers and communities together to improve the homes and lives of low-income homeowners. The mission of Hammers of Hope is to assist those who do not have the means or ability to make home repairs themselves, particularly homeowners who are over the age of 60 or individuals with disabilities. Applicants must currently live in Jefferson County, and only residents located within Jefferson County are eligible to apply. The attached application MUST be signed by the homeowner(s), completed and turned in with all proof of income documents that apply to you and those who live in your home. A check list of documents needed has been provided. Please understand that returning the application or a visit to your home by someone from Hammers of Hope does NOT mean you will be accepted into the program. If you are selected to receive a window unit, volunteers will deliver and install the unit for you. You must sign a Hold Harmless Agreement and once the unit is delivered it becomes your property. Hammers of Hope would like to help everyone who needs assistance, but funding resources and volunteers dictate how many homeowners we can assist. Unfortunately not everyone who applies to the program will be able to get assistance. The back of this letter contains the income guidelines and a check list of documents that MUST be returned with your application. Incomplete applications and those returned without the required documents listed above, may disqualify you for consideration for the AC units. You will be notified by letter whether if you have been selected by Hammers of Hope to receive the AC unit. As stated, to receive services, homeowner(s) must be willing to sign a Hold Harmless Agreement protecting the partnering agencies and their volunteers from any cause of action, claim, loss, demand, or suit arising from or related to: the presence of any Hammers of Hope Affiliate on or about the premises, any services provided by any Hammers of Hope Affiliate; negligence or any damages to personal or real property; or any injuries sustained by the homeowner, family members, or friends. This Hold Harmless Agreement shall serve as a waiver that your story and any pictures taken can be used for fundraising, volunteer recruitment and promotional purposes.. If you have any questions, call , extension 106 or 112 and leave a detailed message. Sincerely, Dennis Murphy Program Manager A program of JCCP Created P:\Departments\CC-HOH\Applications

2 HAMMERS OF HOPE AC PROGRAM Mission Statement: Hammers of Hope is intended to be a safety net that provides home repairs at no cost to the homeowner, focused on safety, increased independence, and greater accessibility issues to low-income families, seniors, and persons with disabilities, who have exhausted all available assistance options. Hammers of Hope is a cooperative charitable effort made possible by Jefferson County Community Partnership (JCCP) and a coalition of home repair volunteers, contractors and agencies. Typical repairs provided include minor carpentry, plumbing, electrical, plastering, painting, glazing, and cleaning. HOH also constructs ramps for persons with accessibility issues. The focus is to keep homeowners living independently in safety and comfort. HOH would like to be able to help everyone who needs assistance but services are available based on funds and volunteer availability. ELIGIBILITY: 1. Applicants must live in Jefferson County and meet the low-income guidelines below. 2. Applicants must provide proof of residency in Jefferson County. 3. Applicants must meet income eligibility guidelines and provide documentation of total household income for all persons living in the home. 4. Seniors 60 and older, people with urgent medical needs and persons with disabilities shall be deemed as priority cases. 5. Applicants must provide proof of age. 6. Applicants must provide a list of other agencies contacted and denied services. Maximum Household Income Guidelines based on 110% of HUD 2015 Jefferson County Very Low Income: Family Size (Check one) Annual Income (Check one) Monthly Income One Person $27,115 $2,260 Two Persons $30,965 $2,580 Three Persons $34,815 $2,901 Four Persons $38,665 $3,222 Five Persons $41,800 $3,483 Six Persons $44,880 $3,740 Seven Persons $47,960 $3,997 Eight Persons $51,040 $4,253 APPLICATION CHECKLIST (please provide those items that apply to you and those who live with you): All Benefit Letters should be dated within the last two (2) months. Previous Year Income Tax Form 1040 Disability benefit letter Circuit Breaker Form SSI benefit letter TANF benefits letter Pension/Annuity benefit letter Unemployment benefit letter Veteran benefit letter Most recent paid Property Tax Bill Child Support benefit letter 2 Food Stamp award letter 2 Most Recent bank statements Copy of Valid State ID or License Rental Income Verification Interest/Dividends statements Signed Application Most Recent Payroll Stubs Social Security Benefit Letter

3 AC for Seniors/Cool Down St. Louis-Jefferson County Air Conditioner Application 3875 Plass Rd Bldg A Phone: Dennis Murphy x106 Phone: Tom Rojas x112 Fax: Website: SECTION A HOMEOWNER INFORMATION Please Print Clearly Name(s) of Homeowners: Mr. Mrs. Ms.: Office use-date received Approved Denied Referred Case # Address: City: Zip Code: Home Phone: Cell Phone: Work Phone: Emergency Contact Name: Emergency Contact Number: Please check ethnicity: White African-American Hispanic Native-American Asian Other: Veteran: No Yes Spouse of Veteran Branch: Rank: Dates of Service: How many years have you owned this home? Amount of house payment: $ Total Number of people living in the home? (list names below) Have you ever applied to Hammers of Hope? Yes No Has Hammers of Hope ever done work on your home? Yes No If yes, what year(s) How did you hear about the program? Elected Official Flyer TV Radio/Newspaper Website Social Worker Friend/Relative Neighbor Facebook Other: List the names and current age of ALL people living in the home, including applicant (attach list if more space is needed): Full Name Date of Birth Relation to Homeowner Gender List all Disabilities 1. Homeowner

4 SECTION B PROVIDE INCOME FOR ALL HOUSEOLD MEMBERS YOU MUST PROVIDE COPIES FOR ALL DOCUMENTS LISTED BELOW THAT APPLY TO YOU. Monthly GROSS Income Amounts (before taxes) Employment Wages Name Name Name Name Name Name Social Security Disability/SS Pension/Annuities Unemployment Rental Income Child Support Food Stamps Unemployment Other Income Total Gross Monthly Income List the amount of EACH PERSON'S ASSETS. If you do not have a certain asset, write "N/A." Checking Account Savings Account Certificate of Deposit IRA/Mutual Funds/Stock You MUST provide All income information and documents for each person listed above. Acceptable Documents: Benefit letter dated within last 2 months for: Social Security, Disability, SSI, Pension/Annuities, Veteran Benefits, Child Support, Food Stamps and Unemployment. Copies from previous years for: Income Tax Form 1040, TANF, Circuit Breaker Form. Current Interest/Dividends statements. 2 most recent Payroll Stubs. Full Bank Statements for all accounts for last 2 months. IF all income documents are not enclosed, your application cannot be processed.

5 Section C HOUSE INFORMATION Check the one that applies: I live in a standard residence I live in a I live in an apartment List other agencies contacted and denied services: I understand this application is to receive a window air conditioner only? Yes No General Release Form: I/we hereby authorize Hammers of Hope or its designated agents to obtain and receive all records and information pertaining to eligibility for the rehabilitation program, including employment, income (including IRS returns), credit, banking information, and residency and from all persons, companies, or firms holding or having access to such information. Hammers of Hope or its designated agents have the option to release this information for the purposes of volunteer education. This authorization, shown as original signature or photocopy, hereby gives Hammers of Hope the right to request all information it can or could obtain from any person, company or firm on any matter referred to above. I/we agree to have no claim for defamation, violation of privacy, or otherwise, against any person or firm or corporation by reason of any statement or information released by them to the Hammers of Hope for the purposes of the program. The term of this authorization shall commence on the date of signature(s) and be in force for a period of five (5) years. My signature below indicates that the information provided herein is accurate and complete. I have read the information provided by Hammers of Hope and have a basic understanding of the program and its process. I give Hammers of Hope with volunteers my permission to inspect my home for purposes of house selection and/or repair. I would like my information shared with other agencies that might be able to help me. I certify that all the information in this application is true and complete. Applicant Signature: Date: Applicant Signature: Date: RETURN APPLICATION and PROOF OF INCOME DOCUMENTS TO: Hammers of Hope 3875 Plass Road, Bldg. A Questions? Call ext. 112 and leave a detailed message or Homeowner Hold Harmless Agreement I affirm that in consideration of the work to be performed free of charge by Hammers of Hope, a charitable effort coordinated by Jefferson County Community Partnership and community volunteers on and about the premises (as defined herein), I, as the owner/resident of the premises and the beneficiary of the air conditioning unit installed thereon, for myself, my heirs, assigns, executors, and administrators, hereby release and hold harmless Hammers of Hope, a charitable effort coordinated by Jefferson County Community Partnership and its affiliates, officers, directors, employees, agents and volunteers (collectively Hammers of Hope Affiliates ) from any cause of action, claim, loss, demand, or suit arising from or related to: (1) the presence of any Hammers of Hope Affiliate on or about the premises; (2) any services provided by any Hammers of Hope Affiliate; (3) the negligence of any Hammers of Hope Affiliate; (4) any damages to personal or real property; or (5) any injuries sustained by myself, any of my family members, or any of my invitees. (6) I also agree to have any pictures taken of me or my project to be used for promotional purposes. (7) I agree to accept the work performed by Hammers of Hope in an AS IS condition. (8) I authorize the completion of this work and the presence of Hammers of Hope Affiliates on the premises of this purpose. Signature of Applicant: Date: Signature of Witness: Date:

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