<%@ Language=VBScript %> <% %> Rebuilding Together - Atlanta
Rebuilding Together Atlanta
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Members Entrance

Homeowner Application

Name:
Address:
Zip code:
Phone:
Age:
Number of years at this address:
Names, ages, and relationship of all persons living in home:
Do you own your own home? yes no
Do you plan to sell your home within the next 18 months? yes no
Do you own other property? yes no
If so, what is that property used for?
Is homeowner or anyone else residing in the home disabled? yes no

If yes, please indicate by checking below all that apply:

Sight Impaired Hearing Impaired
Mobility Impaired
Other Impairments (Please List)
Total Household Income:

List all sources of Income (i.e. Social Security, SSI, AFDC, VA Benefits, etc.)

Should your home be approved for repairs, what would you like done? (Resources are limited and not all repairs)

Electrical Exterior Painting Interior Painting
Plumbing Wall Repairs Roof Repairs
Yard Work Floor Repair Door Repair
Disability Access Other (Please Specify)  
Have you ever applied to Rebuilding Together Atlanta in the past? yes no
If yes, when?
Has your home received services from Rebuilding Together Atlanta? yes no
If yes, when?

HOMEOWNER UNDERSTANDING

  • I understand that participating in the Rebuilding Together Atlanta program is completely voluntary.
  • I understand that I am certifying that I own and live in my home at the address noted on this application, that it is my only residence, and that I have the legal right to make repairs to the property.
  • I understand that providing the information about my household and income will be held in confidence and only used by Rebuilding Together Atlanta for the purpose of determining whether the household meets the criteria set forth by Rebuilding Together Atlanta for assistance.
  • I understand that filling out this application and having my home inspected by Rebuilding Together Atlanta volunteers is to determine whether my home will be adopted by Rebuilding Together Atlanta for future work.
  • I understand that Rebuilding Together Atlanta cannot promise my home will be selected for assistance at this time. My home currently is being considered for repairs, but there is no guarantee that my home will be selected . I understand that I should continue pursuing other avenues for assistance while I wait for the decision of Rebuilding Together Atlanta.
  • I give permission for Rebuilding Together Atlanta to take or have taken photographs, videos or other recorded media of myself and/or my house for use by them or their sponsors to promote or raise funding for Rebuilding Together Atlanta.
  • I understand that Rebuilding Together Atlanta is a volunteer organization and that all work accomplished by Rebuilding Together Atlanta, its volunteers or professionals hired by Rebuilding Together Atlanta will be accomplished without any charge to me , the homeowner. All costs of approved work conducted during the project will be paid by Rebuilding Together Atlanta.

 

Homeowner Signature: Date:
Homeowner Signature:
(if more than one homeowner)		 Date:
Witness: Date:

 

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