Rebuilding Together

Please complete the homeowner application


* - Required field

Basic Information
* Application Date
* First Name
* Last Name
Middle Name
Mailing Address 1
Mailing Address 2
Mailing City
Mailing State
Mailing Zip
Physical Address 1
Physical Address 2
Physical City
Physical State
Physical Zip
Home Phone
Work Phone
Work Phone Extension
Cell Phone
Email Address
County
Ethnicity
Detailed Ethnicity
* Gender
Age Group
Date of Birth
Source
Other Contact
Name
Relationship to Homeowner
Address
City
State
Zip Code
Non-Homeowner Home Phone
Non-Homeowner Work Phone
Non-Homeowner Work Extension
Non-Homeowner Cell Phone
Application
General Areas
Other Area
Comments
Best Time to Call
Hear About
Head of Household
Are you employed?
Disabilities
Annual Income
$
Disability Comments
Monthly Mortgage Payment
Other Government Assistance
Number of Pets
Types of Pets
Do you own your home or have Tenancy for Life Agreement?
Years in Home
Plan to sell home in the next year?
Do you have Homeowners Insurance?
Taxes or other Liens on Home?
Taxes or Liens Description
Current Taxes Paid?
Any family members help with repairs?
If no family members can help with repairs, why not?
In and Out of shower with ease?
Get to bathroom easily?
On and Off toilet with ease?
Smoke/Fire/Monoxide Detectors?
Veteran?
Single/Widowed?
HomeType
Do you receive any other assistance?
Governmental Assistance
Checking/Savings Account Balance
$
IRA/401 K Balance
$
CD Balance
$
Stock and Bond Value
$
Own Other Property?
Number of Bedrooms
Number of Bathrooms
Number of Living Rooms
Number of Other Rooms
Recent Repairs/Modifications
How will these repairs/modifications be important to you or help you or your caregiver?
Personal Caregiver?
Something about yourself
Signed Consent?
Total number of residents in household
What Duneland Elementary School do you live near?
Names listed on title of home
Other Residents
Residents Pay Rent?
If yes, how much rent do they pay?
Residents Living With You
This entry will be deleted on submit!
 
Name
Relationship
Age
Employed
Disabled
Gender
Age Group
Ethnicity
Veteran