Armstrong Habitat for Humanity - A Brush with Kindness

Volunteer Repair Program

Application Form

 

 

APPLICANT INFORMATION

Homeowner’s Name

Home Phone

Address

Work Phone

City, State

Zip Code

Cell/Other Phone

 

DATE OF BIRTH: ___/___/________                        GENDER:          [   ] Male   [   ] Female

 

DISABLED:  [   ] Yes    [   ] No     Have you ever applied for this program before? [   ] Yes [   ] No

                                   (Please note:  Prior application does not disqualify you from participation.)

 

 

List the total household income below:  (Include income received by/for each person in the household.)

Amount

 

$                           per

Source(s)

 

List the name and age of all household residents below:

                     Name                                       Age                                       Name                              Age

1.  Homeowner’s Name

 

 

5.

 

2.

 

 

6.

 

3.

 

 

7.

 

4.

 

 

8.

 

 

Type of Work Needed: (Check all that apply.)

 

[   ] Handicap Ramp                   [   ] Exterior Paint                  [   ] Other _______________________

 

 

       

ELIGIBILITY REQUIREMENTS:

  1. Applicant must provide proof of income qualification (W2, recent pay stubs, SSI letter, etc…)
  2. Applicant must provide proof of homeownership (copy of deed, tax record, etc…) and must reside in the home.
  3. Applicant must agree that the use of a volunteer workforce to provide labor for housing repairs is acceptable to the applicant and by signature below the applicant hereby authorizes the use of such volunteer labor on the applicant’s house. 
  4. Residents from the home must actively participate during the repairs.
  5. The Repair Program is designed to assist homeowners with repairs needed upon their own home. In the event that the homeowner chooses to sell their home within two years of repairs being performed through this program, the homeowner may be responsible for repayment of repair costs at the time of the sale of the home.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CERTIFICATION

 

 

 

By signature below, the undersigned applicant hereby certifies the following:

 

·         All information I have provided in connection with this application is true and correct and I understand that any fraudulent or otherwise intentional misrepresentation may result in criminal and/or civil liability including fines, imprisonment and/or repayment of funds.

 

·         I have read the eligibility requirements listed above.  I understand them to my satisfaction, and I agree to abide by those requirements as they apply to this application.

 

____________________________________________                     _________________________                                        Signature                of Applicant                                                                                                           Date

 

Return to:  Armstrong Habitat for Humanity, PO Box 837, Kittanning, PA 15701

Phone: 724-467-2771       e-mail: mike@armstronghabitat.org

 

Application does not guarantee that Habitat will perform the repairs. The number of home repairs available is dependent upon organizational resources, funding and volunteer support.