APPLICATION FOR HOME REPAIR

Transcription

1 Maumee Valley Habitat for Humanity 1310 Conant St. Maumee, OH Fax APPLICATION FOR HOME REPAIR Date: Applicant Name: Address: City: State: Ohio Zip: Phone #: Cell #: Birthdate: Social Security Number: Address: Number of years at current address: U.S. Citizen: Yes No Are you currently enlisted, a veteran or a spouse of a veteran/military personal? Yes No Are you affiliated with an organization/faith group who would be willing to help on the project? If yes, what group: Co-Applicant Name: Address: City: State: Ohio Zip: Phone #: Cell #: Birthdate: Social Security Number:

2 Income Please send the most recent pay stub with the application Applicant current employer: Years of employment: Business phone: Co-Applicant - current employer: Years of employment: Business phone: Please send the most recent pay stub with the application Dependents Please list individuals who live within household that are legal dependents Name Birth Date Relationship

3 Marital Status: Applicant Married Single I do not wish to furnish this information Please select which best represents your race/national origin: Applicant Unknown American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Black/African-American Caucasian Black/African-American and Caucasian Other (specify) Co-Applicant Please indicate you Ethnicity: Hispanic Non-Hispanic Persons with Physical Disabilities: Male Female Applicant Co-Applicant Employment $ $ SSI $ $ Social Security Disability $ $ Food Stamps $ $ Social Security $ $ Retirement $ $ VA $ $ Child Support $ $ Alimony $ $ AFDC/TANF $ $ Other $ $ Total $ $ Copies of all income must be included with this application

4 Estimated Monthly Bills Please Estimate Your Monthly Expenses Mortgage $ Home Insurance $ Gas $ Electric $ City Utilities (water bill) $ Property Taxes $ Phone $ Cable $ Cell Phone $ Car Payment $ Car Insurance $ Auto Fuel $ Prescriptions/Doctor $ Personal $ Other $ Total $

5 Authorization and Release I understand that by completing this application, I am authorizing Maumee Valley Habitat for Humanity to: 1) Evaluate my actual need for a Habitat for Humanity Home Repair. 2) Evaluate my ability to repay the 0% interest payment. 3) Evaluate my willingness to be a partner family. I understand that the evaluation will include personal visits, a credit check and employment verification. I have answered all the questions on this application truthfully. I understand that if I have not answered the questions truthfully, my application may be denied, and that even if I have already been selected to receive a home repair, I may be disqualified from the program. I understand that I am committing to live in the home for at least two (2) years after completion of the project. The original or a copy of this application will be retained by Maumee Valley Habitat for Humanity even if the application is not approved. I authorize Maumee Valley Habitat for Humanity to obtain a credit report on each applicant. This information may be used to establish credit worthiness to fulfill the debt obligation. I acknowledge that I will be responsible to pay a 10% down payment for the repairs, followed by monthly payments (at zero percent (0%) interest). As part of my sweat equity requirement, I will be present for the duration of the home repair. Exceptions must be discussed with the Maumee before work begins. I will allow volunteers to use my bathroom and provide drinking water. I will also grant permission for volunteers to help with the home repairs. I also agree to offer a helping hand in my community. As part of my sweat equity requirement, I will ensure that the exterior and interior areas to be repaired will be clean of all debris and any objects that may interfere with the repairs. Applicant signature Date: Co-applicant signature Date: ALLOW DAYS FOR YOUR APPLICATION TO BE PROCESSED.

6 Safety and Health Home Repairs Needed Please provide a brief explanation of your family s situation and why you need these repairs at this time.