Dear Homeowner:
Thank you for your interest in Rebuilding Together. Enclosed is an application for our
services. Our mission is to make homes safe, warm and dry in order that elderly
homeowners may remain living independently. Typical work includes repairing or
installing windows, doors, locks, ramps, grab bars, handrails, hand-held showers, raised
toilet seats, interior and exterior paint, minor plumbing and electrical, and roof leaks. A
limited number of new roofs may be provided. Rebuilding Together does not make
structural or foundation repairs.
In order to be eligible for repairs, the following conditions must apply:
 You must be 55 years of age or older
 You must own and reside in your home with plans to remain in your home
 You must live within our geographical boundaries; North to Danforth Road,
South to SW 89th Street, East to Post Road and West to Countyline Road.
Residents outside of these boundaries cannot be considered at this time.
 You must be financially unable to make the repairs
 You must provide verification of all household income
We receive hundreds of applications each year and are limited in the number of homes
and the areas we can serve. Qualified applicants who have returned a completed
application will be contacted to schedule a home evaluation. After homes have been
evaluated and the applicant has been approved, we will match available resources with
the repair.
Please fill out the enclosed application and return it to:
Rebuilding Together
730 W. Wilshire Blvd., # 108
Oklahoma City, Oklahoma 73116
If you have any questions, please call us at 607.0464.
We look forward to serving you.
- Staff at Rebuilding Together OKC
APPLICATION
“Rebuilding Lives and Neighborhoods…making homes Safe, Warm and Dry”
MINIMUM REQUIREMENTS FOR ELIGIBILTY
-55 years of age
-Live between Post Road & County Line Road and Danforth & S.W. 89th
-Own & live in the home
-Financially unable to make repairs
-Household income cannot exceed 200 % of Federal Poverty Level
Name of Homeowner:
Date of Birth:
Age:
Name of Homeowner:
Date of Birth:
Age:
Address:
City:
Zip:
Phone: (H)
(C)
If you cannot be reached, Contact Name:
Relationship:
Phone: (H)
Is a translator needed? Yes
No
Is this a mobile home? Yes
No
(C)
If so, what language?
(if yes, only qualify for ramp program)
List name(s) as shown on deed:
How many years have you lived in your home?
Do you plan to remain living in your home? Yes___No___
Do you have homeowner’s insurance? Yes___ No___
Insurance Company:
Do you own other property? Yes___ No___ If so, what type?
Is anyone in the home disabled? Yes ___ No___ Please check below all that may apply:
□
Uses Wheelchair
□
Visually Impaired
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Other
□
Uses Walker/Cane
□
Hearing Impaired
□
Other
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Loss of Limb
□
Speech Impaired
□
Other
Other (please explain):
REQUEST FOR HOME REPAIRS
Select work needed in order to make your home safe, warm, and dry, noting any repairs that need
immediate attention.
□
□
□
□
Bathroom Remodel
Interior Paint
Roof
Yard work
□
□
□
□
Doors
Home Modification
Weatherization
Flooring
□
□
□
□
Electrical
Plumbing
Windows
Mechanical Cooling
□
□
□
□
Exterior Paint
Ramp
Wall repair/paint
Mechanical Heating
Other Work:
Does the roof leak? Yes _____ No _____ If yes, where? _______________
Do you have family members willing to help? Yes _____ No _____
HOUSEHOLD SIZE & HOUSEHOLD INCOME VERIFICATION
YOU MUST PROVIDE A COPY OF YOUR MOST RECENT TAX RETURN, BENEFIT
STATEMENT, BANK STATEMENT, ETC. All sources of income must be included (i.e., Social
Security, VA, Pension, Wages, etc.). Separately list all occupants living in your home,
including homeowner(s). Include name, age, relationship and income (if applicable) for all
occupants living in the home (i.e., children, grandchildren, great grandchildren).
Name
Age
Relationship
Total household monthly income
Monthly Income
Before taxes
$
Source
/mo.
HOMEOWNER’S MONTHLY HOUSEHOLD EXPENSES
Mortgage: $___________ Utilities: $__________ Prescriptions: $___________
Medical not paid by insurance: $ ____________
Other (please list separately):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
ADDITIONAL INFORMATION
How did you hear about Rebuilding Together?
Referred by:
Relationship:
Phone:
Is anyone in the home a veteran? Yes ____ No ____
Is anyone in your family a Mason or Eastern Star Member? Yes _____ No _____
Have you applied/received services from Rebuilding Together? Yes _____ No _____
Have you applied for services from another agency? If so, which agency?
______________________________________________________________________________
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY
My signature below certifies that the information provided above is true and complete to
the best of my knowledge. I have read the information provided by Rebuilding Together OKC
and have a basic understanding of the program, its process and the qualifications I must meet to
participate. I give Rebuilding Together OKC volunteers my permission to inspect my home for
purposes of project selection and/or repair.
I also grant Rebuilding Together OKC permission to take or have taken photographs and
film, including television, of my home. I consent and authorize Rebuilding Together OKC, its
advertising agencies, news media and any other persons interested in Rebuilding Together OKC
and its work to use and reproduce the photographs and films and to circulate and publicize the
same by all means including, without limiting the generality of the foregoing, newspapers,
television media, brochures, pamphlets, instructional materials, books and clinical material for
the primary purpose of promoting and aiding its programs and its work.
Signature of Homeowner(s)
Date
THANK YOU FOR APPLYING WITH REBUILDING TOGETHER-OKC!
PLEASE ALLOW 30 DAYS TO EVALUATE YOUR APPLICATION.
Return to: Rebuilding Together, 730 W. Wilshire Blvd., Suite #108, Oklahoma City, OK 73116
For questions: call 405.607.0464 or visit our website www.rebuildingtogetherokc.org