Do you or any member of your household own any other real estate? Do you qualify for Medicaid? May we contact other agencies on your behalf?

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Eileen Walton
6 years ago
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1 Agency (if applicable): Contact Name: Phone Number: Last Name: First Name: M.I: Physical Address: City: Zip: Mailing Address: City: Zip: County: Phone: Social Security #: Gender: Race: Marital Status: Birth date: / / Do you own the home in need of repair? Do you live in the home? # of years in residence: Home Type: (Circle one) MOBILE CONDO DUPLEX SINGLE-FAMILY # people in household: Alternate contact (in case we are unable to reach you) Name: Phone: Do you or any member of your household own any other real estate? Do you qualify for Medicaid? May we contact other agencies on your behalf? Have you previously applied for assistance from WARM? Do you own any pets? Is anyone residing in the home a Military Veteran or the spouse of a Military Veteran? In order to process your application, we need a copy of the following documents; please do not mail originals to us. Proof of Ownership: Information proving you own the home in need of repairs, you live on heirs property, or you have lifetime rights. For example: a copy of your deed, a will, or a county tax statement. In the case of a mobile home, please submit a copy of the title from the North Carolina Department of Motor Vehicles. In the case of lifetime rights, please submit a notarized document signed by all homeowners granting you right to live on the property as long as you live. Proof of Income: Information about your income and for all those living in the household. For example: your last four pay stubs from your employer, your MOST RECENT Social Security, SSI, or Disability statement. These documents should match the list of sources you complete in the Household Information section. Rev 08/2015 WARM Application for Assistance Page 1 of 5

2 Please complete the following information for EACH household member, including yourself. Name Employment Relation to you Birth date Social Sec. # M/F of Household Member Status Self Please complete the following income information for all household members. Please include all salaries, Social Security, SSI, Disability, veteran benefits, pensions, child support, alimony, unemployment, etc. Name of Household Member Source of Income (Salary, Social Security, SSI, Disability, etc.) Monthly Earnings Total monthly income for all household members: FOR OFFICE USE ONLY Review Date: Reviewed by: Homeowner Verification: Deed Tax statement Other: (describe) Background Check: Denied Approved Date: Total household monthly income x 12 equals (annual). Number of persons residing in the household is. Median income for a household of person(s) according to income limits dated is (Median Income) for County. (Annual Income) / (Median income x 2) = The income of the above household as a percentage of the median is %. Please reference HUD 20 Income Requirements for (Circle One) B NH P County Rev 08/2015 WARM Application for Assistance Page 2 of 5

3 I hereby authorize Wilmington Area Rebuilding Ministry, Inc. (WARM, Inc.) to release and/or receive to/from any agency or person ANY information that is relevant to the purpose of providing assistance for my needs and/or the needs of my household. I further authorize WARM, Inc. to complete a criminal background screening on each member of my household, listed on this application, for the purpose of application approval. I understand that the release of this information does not guarantee that assistance will be provided but that without the information, my case cannot be processed for consideration of WARM, Inc. services. I understand confidential information may be collected from relatives, friends, acquaintances, coworkers, employers, other assistance agencies, and businesses with whom I have interacted. WARM, Inc. may release or receive information regarding my social and family history, my employment status, my finances, or any other information they deem necessary to review my application. If my project is selected for WARM services, I agree to allow photographs and videos of my home and any household members present during rebuilding activities. I further agree to allow these to be used for recordkeeping, reporting, marketing, and media publication without using my full name or my address. Homeowner (Print Name) Homeowner (Print Name) Homeowner Signature Date Homeowner Signature Date Address, City, State, Zip The execution of this Consent does not guarantee that the assistance you require or desire will be provided. This information will be given only to one or more social agencies (or to persons requested by a social agency to be provided with this information) which may request it. WARM cannot, and does not, decide whether, or how, any other agency may provide assistance to you. Rev 08/2015 WARM Application for Assistance Page 3 of 5

4 In what year was the house built? How many stories? How many bedrooms? How many bathrooms? Does the home contain asbestos materials? Yes No Is mold present in the home? Yes No Is anyone in the home a smoker? Yes No Water source: (Circle one) PUBLIC WELL Type of sewer system: Power company: Power company account number: Are all utility bills paid up-to-date? Yes No If no, which are behind? Is your mortgage paid up-to-date? Yes No Are your property taxes paid? Yes No If you own a mobile home on a rented lot, is the lot rental payment paid up-to date? Yes No Lot owner name: Phone number: Please list any resources you have for these repairs, such as building materials, funds, or family and friends willing to help perform or pay for the work. This information is for planning purposes only. These resources are NOT required to apply, nor will they be used to determine your eligibility. Please check the repairs needed to make your home safe and secure. Appliance Heating/Air Conditioning Sewage/Septic Repairs Door Repair/Replacement Interior Wall Repair Stairs & Landing Electrical Plumbing Water Supply Repairs Exterior Wall Repair Ramp Construction Window Repair Floor Repair Roof Repairs Other (Please Specify) What is the monthly cost of healthcare, including medical visits and prescriptions? How many colds or infections did residents have during the past year? Describe any contagious diseases or conditions in the household. Describe any respiratory illnesses or other types of chronic or terminal illnesses in the household. Describe any falls, burns, or other accidents in the home. Rev 08/2015 WARM Application for Assistance Page 4 of 5

5 Must be completed. Use back of this sheet if necessary. 1. Please tell us more about your situation so we can understand what you are going through. 2. How is the condition of your home affecting you and any other residents? 3. How do you hope WARM s services will improve your situation? I hereby certify that I own and occupy the home in need of repairs, the information on this profile is correct, all income from each person living in my household has been reported, and I am not preparing my home for sale. I understand that failure to report all income, or deception on this application in any way, may result in WARM, Inc. denying me services, or halting services without notice. I understand this information may be used for statistical reporting, and may be furnished to other agencies which may provide assistance. I understand that submittal of this application does not guarantee that assistance will be provided. I agree to promptly provide WARM any additional information needed to process my application. If I am approved, I understand that WARM reserves the right to halt the project at any time, for any reason. Homeowner Signature Date Homeowner Signature Date Rev 08/2015 WARM Application for Assistance Page 5 of 5

DISASTER RECOVERY APPLICATION FOR HOME REPAIR OR NEW HOME CONSTRUCTION. Name: Date:

DISASTER RECOVERY APPLICATION FOR HOME REPAIR OR NEW HOME CONSTRUCTION. Name: Date: Appalachia Service Project Headquarters: 4523 Bristol Highway, Johnson City, TN 37601 Ph: (423) 854-8800 / Fx: (423) 854-9771 To locate a field office, call the number above or visit: ASPhome.org! DISASTER