A Brush With Kindness Home Repair Program Application HOMEOWNER ONE INFORMATION Homeowner One Name * First Name Last Name Homeowner One Home Phone (###) ### #### Homeowner One Cell Phone * (###) ### #### Homeowner One Age * Homeowner One Date of Birth * MM DD YYYY Homeowner One Email Homeowner One Gender (as listed on your government ID) Homeowner One Race (May select more than one) Asian Black/African American White Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Don’t Know/Don’t Wish to Answer Homeowner One Ethnicity Hispanic or Latino Not Hispanic or Latino Other Don’t Know/Don’t Wish to Answer HOMEOWNER TWO INFORMATION Homeowner Two Name First Name Last Name Homeowner Two Home Phone (###) ### #### Homeowner Two Cell Phone (###) ### #### Homeowner Two Age Homeowner Two Date of Birth MM DD YYYY Homeowner Two Email Homeowner Two Gender (as listed on your government ID) Homeowner Two Race (May select more than one) Asian Black/African American White Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Don’t Know/Don’t Wish to Answer Homeowner Two Ethnicity Hispanic or Latino Not Hispanic or Latino Other Don’t Know/Don’t Wish to Answer PROPERTY INFORMATION Present Address (Street, City, State, and Zip) * Address 1 Address 2 City State/Province Zip/Postal Code Country What year was the home built? * Number of years at this address? * What year did you move into your home? * What type of home do you have? * Single Family Townhome Condo Other Do you own this home? * Yes No Are you a permanent full-time resident of this home? * Yes No Is there a homeowners Association on this property? * Yes No Are the property taxes current on this property? * Yes No Are there any citations/code violations that have not been addressed on this property? * Yes No Do you have homeowners insurance? * Yes No Is your premium for homeowners insurance up to date? * Yes No Through what company do you purchase your homeowners insurance? * What is your policy number? * Are you current on your mortgage payments (or have you paid off your home)? * Current/Paid Off Other REPAIRS REQUESTED Check the type(s) of work you would like done on your home. Remember that the items listed below will be considered for repair, but the final decision on what work can be done with our time and financial resources will be made at the discretion of HFHMCC. Our volunteers are not professionals and may not be able to make all repairs. Please keep in mind that the ABWK Program focuses on minor exterior repairs listed below. * Exterior Painting/Staining Minor Exterior Repairs Gutter Cleaning (One Story Only) Light Landscaping/Clean-Up Wheelchair Ramp Weatherization (Exterior) Please provide details in the space below * HOUSEHOLD INFORMATION How many current household members other than homeowners? * 0 1 2 3 4 5 6 Are you or anyone in your household a person with a disability? Yes No Is any household member active U.S. Military or a Veteran? Yes No WILLINGNESS TO PARTNER To be considered for this program, you must be willing to partner with HFHMCC. This includes participating in the assessment of repairs, meeting deadlines, providing a safe and hospitable work environment for staff and volunteers. You must also agree that you and others in your household will work alongside the Habitat for Humanity of Madison and Clark County volunteers and staff on the repairs made to your home. Your help in your home repair is called “sweat equity.” Reasonable Accommodations will be made for people with disabilities who may be unable to perform "sweat-equity"hours or certain physical activities. Also, other family members or friends may help fulfill the hours or other activities will be substituted. Further information will be provided before the repair is scheduled. The safety of staff and volunteers conducting home assessment and/or repairs is of the utmost importance to HFHMCC. If at any time the safety of staff or volunteers is at risk, they may leave the home immediately and not return to the home until the situation has been remediated. Homeowner One, Check the boxes below to indicate you accept these statements * I am willing to complete sweat equity hours I will require reasonable accommodations I am willing to partner with HFHMCC I am willing to present and provide access to the home for a repair assessment Homeowner Two, Check the boxes below to indicate you accept these statements I am willing to complete sweat equity hours I will require reasonable accommodations I am willing to partner with HFHMCC I am willing to present and provide access to the home for a repair assessment PERSONAL STATEMENT Please write a brief explanation of why you feel you should be selected for assistance under Habitat for Humanity of Madison and Clark Counties’ A Brush With Kindness program and how it will help you. * HOUSEHOLD INCOME INFORMATION Please provide MONTHLY income for all adults in the household Please select all income sources for Homeowner One * Salary/Wages (Gross) Social Security SSI Disability Other Homeowner One's Monthly Total Income * $ Please select all income sources for Homeowner Two Salary/Wages (Gross) Social Security SSI Disability Other Homeowner Two's Monthly Total Income $ Please select all income sources for Additional Adult One Salary/Wages (Gross) Social Security SSI Disability Other Additional Adult One's Monthly Total Income $ Please select all income sources for Additional Adult Two Salary/Wages (Gross) Social Security SSI Disability Other Additional Adult Two's Monthly Total Income $ DECLARATIONS Are you and all adults in your household legal US residents? * Yes No Are you or the co-applicant currently involved in a lawsuit related to your property? * Yes No Do you and/or the co-applicant intend to continue to occupy the property as your primary for at least three years? * Yes No Have you or the co-applicant ever been convicted of a felony? * Yes No Do you and/or the co-applicant agree to continue to maintain the home to the best of their ability (keep neat, clean, and in good repair) so as not to reduce its value or that of the neighborhood? * Yes No AUTHORIZATION, AGREEMENT, AND RELEASE Please read and check each box below to confirm your understanding and agreement: * I certify that the information on this application is accurate and that I own the property at the given address. I certify that verification may be obtained from any source named in this application. I understand that this application can be rejected at any time if information provided is incorrect or untrue. I further declare that I have no intention to move, sell, or rent this residence for at least three years. I authorize Habitat for Humanity of Madison and Clark Counties (HFHMCC) to examine my income, residency, and any other requirements throughout the application process. I understand that HFHMCC will make the final decision regarding the work that can be done at my home and that I will receive a Homeowner Agreement with a scope of work before any repairs are made to my home. Additionally, I certify that no members of our household are currently or will be involved in the future in any type of illegal activity and I authorize Habitat for Humanity of Madison and Clark Counties to investigate my criminal history if necessary. I also understand that Habitat for Humanity screens all applicants and adults (18 years and up) in their household on the sex offender registry. By completing this application, I am submitting myself to such an inquiry. As an applicant, I acknowledge Habitat for Humanity of Madison and Clark Counties has obtained non-public and public information for the application to be processed and that they will keep this information in a secure place and it will not be shared with any unauthorized parties. I further understand that the people who may work on my house are unpaid volunteers and that few, if any of them, are skilled in the building trades. I understand that Habitat’s A Brush with Kindness program make no warranties, expressed or implied, regarding any materials used or work done by any of the volunteers throughout this project. I hereby agree that I will not make a claim against or sue Habitat for Humanity of Madison and Clark Counties and any of our affiliates for injury or damage resulting from negligence or other acts caused by any employee, contractor, or participant in the A Brush with Kindness activities. I hereby release Habitat for Humanity of Madison and Clark Counties and any of its affiliated organizations from all actions, claims or demands that I now have or may hereafter have for injury or damages resulting from my participation in the A Brush with Kindness project. If this application is created as (or converted into) an "electronic application", I consent to the use of "electronic records" and "electronic signatures" as the terms are defined in and governed by applicable federal and/or state electronic transaction laws. I intend to sign and have signed this application either using: (a) electronic signature or (b) a written signature and agree that if a paper version of this application is converted into an electronic application, the application will be an electronic record, and the representation of my written signature on this application will be my binding electronic signature. Date * MM DD YYYY Thank you!
