5238 Peachtree Road, Atlanta, GA Fax:

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1 Dear Homeowner: Thank you for your interest in Senior Connections Home Repair program. We are proud to be able to offer this valuable service in alignment with our mission to help seniors maintain their independence. Senior Connections Emergency Home Repair Program is available to owner-occupants who are 62 years of age or older, and/or disabled. Eligibility requirements for this program may include that the homeowner s income (and occupants) meets income requirements set by our funder(s); location of home, basic homeowner s insurance and the emergency nature of the repair. The emergency nature of the repair is defined as deteriorating conditions that threaten the health and safety of the occupants. The goal of this service is to stabilize life-threatening conditions so that the family s health and safety are no longer an issue. These repairs include, but are not limited to, roof repairs and replacements, plumbing repairs, furnace repair/replacement, electrical wiring, carpentry, floor structures, wheelchair access/modifications, window and gutter replacements, and general maintenance. In order for your application to be considered and/or placed on the waiting list please provide the following : Completed Homeowner Application Signed Homeowner s Agreement of Understanding Signed Senior Connections Eligibility Release Form Copy of Warranty Deed Proof of Annual Household Income Proof of Homeowner s Insurance Proof of Residency (utility bill) Copy of Photo ID Copy of DD214 (veterans only) to the following mailing address: Senior Connections 5238 Peachtree Road Atlanta, GA Attn: Home Repair After a review of your documents, program staff will determine your eligibility to receive home repair services. Once you have been determined eligible, you will be contacted to schedule an assessment at your home. During the assessment visit, the Senior Connections representative will go over the program details and paperwork, and will answer any questions you may have. Please note eligibility does not guarantee approval of project. Thank you for your prompt attention to this matter. We look forward to serving you and improving your quality of life at home. If you have any questions, please call. Home Repair Specialist Enclosures noted as above 5238 Peachtree Road, Atlanta, GA Fax: rev

2 Page 1 of 3 Homeowner Application Home Repair Program 2015 (Please answer the following questions as complete as possible. If you are not sure, answer unknown and if not applicable please answer N/A) Homeowner(s): Mr/Mrs/Ms Address: City: Zip: County: Home Phone: Cell Phone: D.O.B Neighborhood Planning Unit or Community: Year home was built: Approximate Value: How many years have you lived at this address? Do you currently occupy the home? If no, why not? Do you plan to sell your home within the next 24 months? Is homeowner or other person(s) residing in the home disabled? Yes No If yes, please indicate by checking below all that apply: Sight Impaired Hearing Impaired Mobility Impaired Other impairment (s) Are you a veteran? Yes No If yes, what branch Years served Era served (ex. WWII, Vietnam) 5238 Peachtree Road, Atlanta, GA Fax:

3 Page 2 of 3 Names, ages and relationships of all persons living in the home: Name Age Relationship Handicapped/Disabled Income / Employment Disclosure: Household Income Check all income sources that apply (include income from all sources for all adult household members over the age of 18) Employment Union Benefits Family Support Unemployment Compensation Income from Assets AFDC Self-employment Pension SSI Social Security Retirement Funds Rental Income Worker s Compensation Child Support Alimony Disability Other List the total gross income (before deductions), for each adult member (18 years or older) of the family living in the home. For self-employed family members, a certified profit & loss statement must be included with application package. Breakdown of Household Income Household Member Source of Income* Monthly Annual Total Annual Household Income = *If income is based on commission or self-employment, show amount earned to date or list income from previous year 5238 Peachtree Road, Atlanta, GA Fax:

4 Page 3 of 3 Have you ever received funded home repair assistance? If yes, when? Provider? Repairs desired (be specific, use additional paper if necessary) Plumbing Roof Electrical Furnace Air Conditioner Windows Weatherization Insulation Flooring Disability Access Other APPLICATION CERTIFICATION I/We and hereby certify, under penalty of perjury, that I/we are the property owner(s) and that the statements and information included in the application are to the best of my/our knowledge and belief, in all respects true and correct. Homeowner Signature Date Homeowner Signature Date If you have questions please contact Senior Connections at for TTY Callers Dial GA RELAY 711 It is the policy of Senior Connections to provide equal home repair services to all qualified applicants, without discrimination based on race, color, religion, gender, age, national origin, disability, or any other protected characteristic as established by law 5238 Peachtree Road, Atlanta, GA Fax:

5 Homeowner s Agreement of Understanding I understand that participating in the Senior Connections Home Repair Program is completely voluntary on my part; I understand that I am certifying that I own and live in my home at the address noted on this application; that it is my only residence, and that I have the legal right to make repairs to the property; I understand that providing the information about my household and income will be held in confidence and only used by Senior Connections for the purpose of determining whether the household meets the criteria set forth by Senior Connections for assistance; I understand that filling out this application and having my home inspected by Senior Connections staff and/or contractors is to determine where my home will qualify for Senior Connections repair program; I understand that Senior Connections cannot promise that my home will be selected for assistance at this time. I understand that my home is currently being considered for repairs, but there is no guarantee that my home will be selected. I understand that I should continue pursuing other avenues for assistance while I wait for the decision of Senior Connections; I give permission for Senior Connections to take or have someone take photographs, videos or other recorded media, of myself, household family members, and/or my house for use by them or their sponsors to promote or raise funds for Senior Connections; I understand the I will make myself available once repairs are completed for any required sign-off procedures and surveys; I understand that Senior Connections is a 501(c)(3) non-profit organization and that Senior Connections works with independent inspectors, contractors and volunteers to complete home repair projects; and I ve enclosed copies of the requested documents listed of cover letter to determine eligibility. Homeowner(s) Signature: Signature: Please Print : Print: Date: Date: Witness: Date: 5238 Peachtree Road, Atlanta, GA Fax: (For TTY Callers Dial GA Relay 711)

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7 5238 Peachtree Road Atlanta, GA Senior Connections' Home Repair Program Frequently Asked Questions Q: What is this program all about and what can it do for me? A: Senior Connections is the administrator or program sponsor of funds received through grants or private donations. The funds are allocated according to the guidelines required by the funding source. Minor repairs may be performed under this program with Senior Connections. Q: Am I eligible for the program? A: To be eligible you must be 62 years old, live in an area designated by the particular program, must not have any outstanding liens on your property, must own and reside in the home to be repaired, meet income level requirements and the repairs requested must fall within the program budget for a single home. Q: I am told that I do not have to pay anything for a repair made to my home is this correct? A: Yes. The funding source provides all the money to make the repairs listed on the Approved Repairs and Work Completion form by your Project Coordinator and agreed to by you. Q: Will there be a lien on my home for the repairs made? Why? A: No Q: Why do you need a copy of my deed? We need a copy of your deed to show proof that you are the homeowner. If there are others listed on the deed we must verify that you have the right to make repairs/changes to the home. Q: Will I have to sign any other paperwork? A. Yes. You will be asked to sign the following: 1. Completed Homeowner Application 2. This Frequently Asked Questions form. 3. Homeowner s Agreement of Understanding 4. Eligibility Release Form 5. Release of Information" form Peachtree Road, Atlanta, GA Fax: last revised

8 Q: Will my current monthly mortgage payment increase? A: No. See below if your taxes are impounded by your mortgage company. Q: Will this lien increase my taxes? A: Not necessarily, however, if the repairs to your home are significant and the county decides to reappraise your home, then your taxes MAY go up. Q: Are there any hidden costs or conditions that I need to know about? A: No not exactly, however, Senior Connections does incur an administration cost to manage the program. In other words, if we do repairs to your home the cost will be higher than what you would be charged if you contracted directly with the contractor. That additional amount would be our cost to administer the program if we both were using the same contractor. Q: May I take a copy of all the paperwork to my lawyer or an advisor look at it? A: Yes. I have read and understand the contents of this form. (Signature) (Date) (Signature) (Date) (Print Name) (Print Name) 5238 Peachtree Road, Atlanta, GA Fax: last revised