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Homeowner Application

Step 1 of 10

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Property Information:
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone*
Cell Phone*
Email
Owner occupied?*
- Yes
- No
Number of persons living in the home?*
If Single Family, number of bedrooms:
If Multi Family, number of units:
Is the property being purchased by Land Contract?*
- Yes
- No
Is the contract recorded?*
- Yes
- No
Purchase price of home:*
Date of purchase:*
MM slash DD slash YYYY
Balance owing:*
Are the property taxes current?*
- Yes
- No
Do you have property insurance?*
- Yes
- No
Name of insurance company:
Address of insurance company:
Street Address Address Line 2 City State ZIP Code

What is the nature of the problem(s) to be repaired?*
- Electrical
- Wheelchair Ramp
- Roof Repairs
- Floor Repairs
- Exterior Painting
- Plumbing
- Concrete Repairs
- Door Repairs
- Interior Painting
- Wall Repairs
- Yardwork
- Other – please explain below
Please explain other:
How did you hear about us?*
Have you applied for assistance from Rebuilding Together before?*
- Yes
- No
Have you received assistance from Rebuilding Together before?*
- Yes
- No
When?
MM slash DD slash YYYY

Homeowner Information:
Homeowner 1:
Name*
First Last
Age*
Date of Birth*
MM slash DD slash YYYY
Sex*
- Male
- Female
Marital Status*
- Married
- Single
- Other
Currently Employed?*
- Yes
- No
- Retired
Number of years with employer
Name of employer
Address of employer
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone of employer
Disabled*
- Yes
- No
Veteran*
- Yes
- No
Social Security (SSI)*
- Yes
- No
If disabled, briefly describe any limitations due to your disability.

Homeowner 2:
Is there a second homeowner?*
- Yes
- No
Name*
First Last
Age*
Date of Birth*
MM slash DD slash YYYY
Sex*
- Male
- Female
Marital Status*
- Married
- Single
- Other
Currently Employed*
- Yes
- No
- Retired
Number of years with employer
Name of employer
Address of employer*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone of employer
Disabled*
- Yes
- No
Veteran*
- Yes
- No
Social Security (SSI)*
- Yes
- No
If disabled, briefly describe any limitations due to your disability.
Relationship of homeowners (spouses, parent-child, other)*
Number of years homeowner(s) has lived in the home*
Number of adults living in the home*
Number of adults receiving income*
Number of children living in the home*
Ages of children

Please provide a referral source: (someone we can contact to verify information)
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*

Mortgage Information
Name of the mortgage company*
Phone number*
Address*
Street Address Address Line 2 City State ZIP Code
Have you missed a mortgage payment in the last 12 months?*
- Yes
- No
If yes, how many?

Income and Expense Information
Monthly Income Information
Salary*
Social Security/Disability
Social Security/Disability(2)
Child Support/Alimony
Rental Income
VA Income
VA Disability Compensation
Other
Other
Total Monthly Income

Monthly Expense Information
Mortgage Payment
Property Insurance
Property Taxes
Gas and Electric
Water Bill
Home Phone
Mobile Phone
Cable TV/Satellite TV
Trash Service
Medicine
Car Payment
Car Insurance
Life Insurance
Total Monthly Expenses

Loans and Creditors
Company Name
First Last
Company Address
Street Address Address Line 2 City State ZIP Code
Loan Amount
Monthly Payment
Balance Owed
Is account delinquent? Why?
Company Name
First Last
Company Address
Street Address Address Line 2 City State ZIP Code
Loan Amount
Monthly Payment
Balance Owed
Is account delinquent? Why?
Company Name
First Last
Company Address
Street Address Address Line 2 City State ZIP Code
Loan Amount
Monthly Payment
Balance Owed
Is account delinquent? Why?
Company Name
First Last
Company Address
Street Address Address Line 2 City State ZIP Code
Loan Amount
Monthly Payment
Balance Owed
Is account delinquent? Why?
Company Name
First Last
Company Address
Street Address Address Line 2 City State ZIP Code
Loan Amount
Monthly Payment
Balance Owed
Is account delinquent? Why?

Required Documentation:

1) If employed – two most current and consecutive paystubs, and the name and address of employer.

2) Other income – if you are disabled and receiving SSI or VA compensation provide a copy of your statement of benefits.

3) Current mortgage statement if applicable.

4) Liquid assets: If liquid assets exceed $5,000, provide account names and amounts.

IMPORTANT – READ CAREFULLY BEFORE SIGNING

Applicant’s Statement:

I certify that I do not have the financial means (savings, investments, etc.) to perform the repairs for which I am applying. I certify that the above statements are true, accurate, and complete to the best of my knowledge and belief. This application shall remain the property of Rebuilding Together, to which it is submitted for the purpose of obtaining assistance.I hereby consent to and authorize Rebuilding Together, after giving reasonable notice, to enter the property for the purpose of determining the need and scope of the repair(s)specified above. I authorize the disclosure of the above information to only those persons or agencies as necessary to secure the assistance for which this application is submitted.

Warning!! It is a federal crime, punishable by fine and/or imprisonment, to knowingly make false statements concerning any of the above facts as applicable under the provisions of Title 18, US Code, Section 1014.
Homeowner 1 Signature*
Homeowner 2 Signature

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