Apply for Assistance

2017 Homeowner Application

Print the form below and mail to:
Rebuilding Together Hebron
PO Box 825
Hebron, IN 46341

If you have any questions, please call Deb McKay at 219-996-6032 and she will be glad to help!

Rebuilding Together Hebron

2017 Homeowner Application

April 29, 2017 Workday

___Mr. & Mrs. ___Mr. ___Mrs. ___Ms.

Name: _______________________________________________________

Address: _____________________________________________________

Town: ________________________ State: ________ Zip: ___________

Phone: Home: _______________________ Cell _______________________________

Age of Applicants: _______/________ Is there a veteran living in the home? ________

Is REMC your utility company? __________

Are you employed, and if so, who is your employer? _____________________________

Please list everyone other than the applicant living in the house

Name                               age             relationship                employed

___________________ /_____ /  _________________ / __________________

___________________ /_____ /  _________________ / __________________

___________________ /_____ /  _________________ / __________________

___________________ /_____ /  _________________ / __________________

 

Total Household income $ ________/ month. Include income from all people living in the home. Please provide proof of income such as last year’s tax return, determination letter, paycheck stubs, etc. for everyone living in the home.

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Property Information: Do you own your own home? __________

Year home was built: _____ Number of bedrooms _____ Number of bathrooms ______

For participation in the program, you must have Homeowner’s Insurance

Insurance Company _________________________ Policy Number ________________

Name of Agent ________________________ Phone number (_____)_______________

Repair Wish List: What are the FOUR most important repairs needed?

1. ______________________________________________________________________

2. ______________________________________________________________________

3. ______________________________________________________________________

4. ______________________________________________________________________

Please provide information about yourself that will be important for us to consider your application such as medical condition. How will the repairs help you?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

I hereby grant and convey unto Rebuilding Together Hebron and/or any person authorized by them all rights, title, and interest in any photographs, recordings, interview, videotapes, motion pictures or similar visual and auditory recordings made by Rebuilding Together Hebron or any of its affiliated organizations during my activities with respect to the project, including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.

I consent to the unrestricted use of my image and that of my family member in connection with the project by Rebuilding Together Hebron or any person authorized by Rebuilding Together Hebron included but not limited to any photographs, audio or video recordings, interviews, videotapes, motion picture or the use of my name in connection with television, radio or print media.  Images may be used on social media outreach.

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If your home is selected, we expect able-bodied family and friends to help on Saturday, April 29, 2017 for our workday. Will you have family and friends to help? If not, why?

________________________________________________________________________

Please initial:

_______ I understand that I am required to volunteer to the best of my ability and that adult family or friends on site during the work day will also participate.

_______ I am the sole owner of the home at the above address OR I share ownership with person or persons who are also eligible to receive this assistance.

_______ This property is my full-time residence.

I/We certify the above information is true and correct to the best of my/our knowledge. I/We realize failure to provide all information requested could result in our application being invalid. I/We authorize Rebuilding Together Hebron to check any references necessary to complete the processing of this application for the purpose of receiving housing rehabilitation through Rebuilding Together Hebron. I/We also understand any information received will be kept confidential and will be used strictly for determining my/our eligibility for this program.

Signature ___________________________________________________

date ______________

Phone: ______________________

Referred by ________________________________________________

Mail to:

Rebuilding Together Hebron

P. O. Box 825

Hebron, IN 46341

Applications received by February 1, 2017 will receive first consideration.

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