P.O. Box 641250 Chicago, IL 60664-1250 312.201.1188 www.rebuildingtogether-chi.com APPLICATION FOR FREE HOME REPAIRS DEADLINE EXTENDED!! Deadline: December 1 st Dear Homeowner: Applications for free home repair will be accepted until December 1st. Early applications will be given priority. Rebuilding Together Metro Chicago (formerly Christmas in April) is a volunteer home repair effort that conducts a one-day community work blitz to help repair the homes of low-income homeowners. Eligibility for the free home repair is based on both financial eligibility and the type of work needed, with priority given to elderly and disabled homeowners. Our program has been in existence for twenty-two years and is composed entirely of volunteers who work at banks, law firms, construction companies, unions, etc. Although we do all of our work in April 2016, we must choose our homes now. For that reason, we ask that you submit your application promptly. We are planning to select about 50 homes in a section of the Austin neighborhood this year. We will have 2 areas of focus this year; (refer to diagram on page 2). Please also encourage others to apply. Complete the application as completely and accurately as you can. If you are being considered for our program, we will ask you to provide proof of your household income and homeownership when we visit you. At that time, we will also want to see the types of repairs that you need. We are so impressed with the community spirit in Austin and look forward to working with residents there during the coming year. Together we can ensure that the investment you have made in your family home is preserved for generations to come. Very truly yours, Wanda Ramirez Executive Director Page 1
Your Alderman is working with Rebuilding Together to provide free home repairs in your ward this year. Call your Alderman to verify the National Rebuilding Day Program! Alderman Emma Mitts Alderman Chris Taliaferro 37 th Ward 29 th Ward 4924 W. Chicago 6272 W North Ave Chicago, IL. 60651 Chicago, IL 60639 312-744-8019 773-237-6460 Do You Live in the 2016 Program Area? Homeowners living in a section of the Austin neighborhood are eligible to apply for free repairs this year. To qualify for repairs to your home, you must be located within this diagram shown below. Division St. Austin Blvd. Cicero Ave. Chicago Ave Laramie Ave Kinzie St If you do NOT live in this area, call our office at (312)201-1188 to add your name to our interest list. We will contact you if your home becomes eligible in the next 3 years. Please pass this application on to a friend who lives in the 2016 program area. Page 2
P.O. Box 641250 Chicago, IL 60664-1250 312.201.1188 www.rebuildingtogether-chi.com APPLICATION FOR FREE HOME REPAIRS 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 30, 2016 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: Email 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: Page 3
11. Do you have a social worker/care manager/home healthcare provider? 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. SOURCES OF INCOME YES Homeowner Income Employment wages? $ $ Co-owner or Spouse Income 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: Page 4
Work Phone: Part D: Veteran Information: Position: Retired: 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 5
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? 1. 2. 3. 4. 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 Basement Pipes Faucet(s) Do you have sparking at your electrical outlets? Page 6
Does your hot water heater work? How do you currently heat your home? Boiler Furnace Space Heater Oven Do you have a pest, bed bug 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 7
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 2. 3. 4. 5. 6. 7. 8. 2. 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 2016? If yes, please list who: 4. Do you expect anyone else to move in before April 2016? If yes, please list who: Page 8
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 9
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 Metro * Metro Chicago Chicago PO Box 641250 Chicago, IL 60664 Page 10