Application:
Name:
Age:
Address:
City: Zip:
Phone:
Names and ages of all persons living in the home:
Do you own your home?
How long have you lived in the current address?
Have you applied to Rebuilding Together in the past? When?
List sources of all income per month (i.e. Social Security, SSI, AFDC, VA Benefits, interest/dividends, etc...)
Is the homeowner or anyone else residing in the home disabled?
If so, indicate special needs (wheelchair or walker, hearing-impaired, etc):
How many children do you have living in the area?
Explain why you or family members cannot do the repairs:
List the most-necessary work needed in order to make your home safe, secure and weatherproof. (Funds are limited and not all repairs can be made).
My signature below indicates that the information provided above is accurate and complete. I have read the information provided by Rebuilding Together of Greater Green Bay and have a basic understanding of the program and its process. I give rebuilding Together volunteers my permission to inspect my home for purposes of home selection and/or repair.
Signature of applicant __________________________________
Date of application ____________________________________
If this form is prepared by someone other than the homeowner, or if assistance is give the homeowner, please complete the following:
Is the homeowner aware of this application?
Name of person assisting with application:
Phone:
Agency:
rev. 03-15-07 Date received: _______________________
Application
