Homeowner
Application
“Rebuilding Lives and Neighborhoods…making homes Safe, Warm and Dry”
MINIMUM REQUIREMENTS FOR ELIGIBILTY
-Home must have been damaged by the May 20th – June 2nd storms.
-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:
Zip:
City:
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:
Disaster Recovery Clients:
Did your have damage to your home in the recent May 20th – June 2nd storms? Yes___ No___
Are you a qualified FEMA Registrant? Yes___No___
What other Government or community organizations have you applied for? _________________
______________________________________________________________________________
______________________________________________________________________________
Have you received any money from your insurance provider? Yes____ No____ If yes how much
money and for what repairs? ______________________________________________________
What are your unmet needs that you have not received funds for? _________________________
______________________________________________________________________________
______________________________________________________________________________
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:
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Uses Wheelchair
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Visually Impaired
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Other
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Uses Walker/Cane
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Hearing Impaired
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Other
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Loss of Limb
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Speech Impaired
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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.
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Bathroom Remodel
Interior Paint
Roof
Yard work
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Doors
Home Modification
Weatherization
Flooring
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Electrical
Plumbing
Windows
Mechanical Cooling
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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
Total household monthly income
Relationship
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
Cleveland County and 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
Cleveland County and Rebuilding Together OKC volunteers my permission to inspect my home
for purposes of project selection and/or repair.
I also grant Rebuilding Together Cleveland County and Rebuilding Together OKC
permission to take or have taken photographs and film, including television, of my home. I
consent and authorize Rebuilding Together Cleveland County and Rebuilding Together OKC, its
advertising agencies, news media and any other persons interested in Rebuilding Together
Cleveland County and 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 CLEVELAND COUNTY AND
REBUILDING TOGETHER OKC! PLEASE ALLOW 30 DAYS TO EVALUATE APPLICATION.
Return to: Rebuilding Together, PO Box 5045 Norman, OK 73070