Homeowner Application

Name(s)
Street Address
City
State
Zip
Phone
Do you own this home?
Backup Phone
Number of years at this address
Do you have homeowner's insurance?
Do you have any past due property taxes?
If yes, how much?
Do you plan to sell your home in the next 18 months?
Names and ages of all persons living in home and their relationship to homeowner:
Combined household income per year (Include all people living in the home: Social Security, rental income, pensions, etc.)
Is the homeowner a veteran of the United States Military?
If so, please describe your branch.
Years of Service
Is the homeowner or anyone else residing in the home disabled?
If so, indicate all that apply:
If your home is selected for rehab work, there will never be a charge for our service. Should your home be selected for rehab and repairs, what are the FOUR MOST IMPORTANT repairs you need at your home?
Is there any additional information about yourself that would be important for us to consider while evaluating your request?
How did you hear about Rebuilding Together?
Captcha
Captcha