Critical Home Repair Application

Dear applicant,

Thank you for your interest in Central Valley Habitat for Humanity’s Critical Home Repair Program.

Please complete this pre-screening application to determine if you qualify for the Habitat for Humanity Critical Home Repair program.

Please fill out the application as completely and accurately as possible. All information you include will be kept confidential.

Thank you for trusting us. Through this program, we aim to help homeowners stay in their homes safely, with dignity and peace of mind.

Your Contact Information

First Name *

Last Name *

Email *

Address Line 1 *

Address Line 2

Phone *

City *

State *

Zip *

Physical Address of Residence: * The field Physical Address of Residence: is required.

1. APPLICANT INFORMATION

Applicant First Name * The field Applicant First Name is required.

Applicant Last Name * The field Applicant Last Name is required.

Applicant Phone Number * The phone field Applicant Phone Number is required.

Applicant Email Address * The email field Applicant Email Address is required.

Applicant Date of Birth * The date field Applicant Date of Birth is required.

Preferred Contact Method * The field Preferred Contact Method is required.

Prefered Languague * The field Prefered Languague is required.

Other The maximum length for the field Other is 500 characters.

Veteran/Military Affiliation * The field Veteran/Military Affiliation is required.

If yes, which branch? The maximum length for the field If yes, which branch? is 500 characters.

Co-Applicants Information

Co-Applicant First Name The maximum length for the field Co-Applicant First Name is 500 characters.

Co-Applicant Last Name The maximum length for the field Co-Applicant Last Name is 500 characters.

Co-Applicant Phone Number The field Co-Applicant Phone Number must be a phone number.

Co-Applicant Email Address The field Co-Applicant Email Address must be an email.

Co-Applicant Date of Birth The field Co-Applicant Date of Birth must be a date.

Co-Applicant Preferred Contact Method

Co-Applicant Preferred Language

Other The maximum length for the field Other is 500 characters.

Co-Applicant Veteran/Military Affiliation

If yes, which branch? The maximum length for the field If yes, which branch? is 500 characters.

Household Members

Who lives in the home in addition to the Applicant/Co-Applicant? (All residents of the home)

1. Name (First, Last) The maximum length for the field 1. Name (First, Last) is 500 characters.

1. Age The field 1. Age must be a number.

1. Relationship to Applicant/ Co-Applicant The maximum length for the field 1. Relationship to Applicant/ Co-Applicant is 500 characters.

2. Name (First, Last) The maximum length for the field 2. Name (First, Last) is 500 characters.

2. Age The field 2. Age must be a number.

2. Relationship to Applicant/ Co-Applicant The maximum length for the field 2. Relationship to Applicant/ Co-Applicant is 500 characters.

3. Name (First, Last) The maximum length for the field 3. Name (First, Last) is 500 characters.

3. Age The field 3. Age must be a number.

3. Relationship to Applicant/ Co-Applicant The maximum length for the field 3. Relationship to Applicant/ Co-Applicant is 500 characters.

4. Name (First, Last) The maximum length for the field 4. Name (First, Last) is 500 characters.

4. Age The field 4. Age must be a number.

4. Relationship to Applicant/ Co-Applicant The maximum length for the field 4. Relationship to Applicant/ Co-Applicant is 500 characters.

Demographics and Agency Info

Select if you currently receive or have ever received assistance from any of these agencies: (Select all that apply) * The field Select if you currently receive or have ever received assistance from any of these agencies: (Select all that apply) is required.

Other The maximum length for the field Other is 500 characters.

2. PRESENT HOUSEHOLD CONDITIONS

Describe the repairs/modifications needed: * The field Describe the repairs/modifications needed: is required.

Is the repair to the roof of your home? * The field Is the repair to the roof of your home? is required.

Please check below which aspect of your home the repairs or modifications will improve: (Check all that apply) * The field Please check below which aspect of your home the repairs or modifications will improve: (Check all that apply) is required.

3. PROPERTY INFORMATION

Is Your Home A Mobile Home? * The field Is Your Home A Mobile Home? is required.

Do you own or rent your home? * The field Do you own or rent your home? is required.

Resident or Rockingham CO/Harrisonburg? * The field Resident or Rockingham CO/Harrisonburg? is required.

Is this home your primary dwelling? * The field Is this home your primary dwelling? is required.

Amount of Monthly Mortgage / Rent Payment? * The numeric field Amount of Monthly Mortgage / Rent Payment? is required.

Unpaid Balance (if mortgaged) The field Unpaid Balance (if mortgaged) must be a number.

Are your Mortgage payments up to date? * The field Are your Mortgage payments up to date? is required.

If not, how many payments behind? The maximum length for the field If not, how many payments behind? is 500 characters.

Property Taxes Paid or in Escrow (if applicable) * The field Property Taxes Paid or in Escrow (if applicable) is required.

Is Homeowners Insurance current (if applicable) * The field Is Homeowners Insurance current (if applicable) is required.

4. MONTHLY GROSS INCOME

What is your combined household monthly income? (Before taxes are taken out) * The numeric field What is your combined household monthly income? (Before taxes are taken out) is required.

Source(s) of income: * The field Source(s) of income: is required.

In order for your application to be considered and reviewed, please email your current monthly pay statements, 2 months of bank statements and your last 2 years of Tax Returns to CHR@centralvalleyhabitat.org,

*DO NOT FORGET TO REFERENCE THE APPLICATION IN THE EMAIL*

5. AUTHORIZATION AND RELEASE

I understand that by filing this application, I am authorizing Central Valley Habitat and Habitat Partners to contact other organizations to evaluate my actual need for the home repair program, my ability to pay a portion of the repair cost and other expenses of homeownership, and my willingness to be a partner through sweat equity. I understand that the evaluation will include personal visits, a credit check, and income 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 home repairs, I may be disqualified from the program. The original or a copy of this application will be retained by Habitat for Humanity even if the application is not approved.

I also understand that all applicants are screened on the sex offender registry. By completing this application, I am submitting myself to such an inquiry. I further understand that by completing this application, I am submitting myself to a criminal background check.

Are you willing to provide Sweat Equity? (5 Hours of Sweat Equity equals $100.00 credit, disabled person unable to contribute sweat equity will receive $50.00 credit) * The field Are you willing to provide Sweat Equity? (5 Hours of Sweat Equity equals $100.00 credit, disabled person unable to contribute sweat equity will receive $50.00 credit) is required.

Repair Costs: The total value of the repair must be no more than $5000. I understand that I will be expected to contribute to the cost of the repairs. The amount due is based on your income and the expected payment could vary but will not exceed 20% of the total cost. The Homeowner must have the ability to pre-pay the subsidized repair cost before work will begin.

I understand that I will be expected to contribute to the cost of the repairs * The field I understand that I will be expected to contribute to the cost of the repairs is required.

By checking the box below, you are agreeing to participate in a network made up of health and social service partners (“The Network”) who work together to connect clients with services to connect you to people/agencies that can help you, we ask you to allow us to share your information with those partners. Your information will be kept confidential and will be used to help you get the services you want. Some partners may ask you to sign another consent or authorization to share your information to comply with federal, state, and local privacy and data protection laws, such as federal HIPAA laws.

I give my consent for the information in this application to be submitted to other agencies for the purpose of the project. * The field I give my consent for the information in this application to be submitted to other agencies for the purpose of the project. is required.

Applicant Signature * The field Applicant Signature is required.

Date * The date field Date is required.

Co-Applicant Signature * The field Co-Applicant Signature is required.

Date: * The date field Date: is required.