Build United Eligibility Application
Email address *
Name of Applicant *
Your answer
Address *
Your answer
Directions to Home *
Your answer
Phone Number- Home *
Your answer
Phone Number- Work *
Your answer
Age of Applicant *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Agency Making Referral *
Your answer
Phone Number *
Your answer
Agency Representative *
Your answer
Agency Mailing Address *
Your answer
Please check if the following statements apply to you *
Required
Do you own your home? *
If no, please explain
Your answer
Is there a mortgage on your home? *
Is yes, please list monthly payment amount
Your answer
Are mortgage payments up to date? *
If no, please explain
Your answer
Are all real estate taxes paid? *
If no, please explain
Your answer
Number of persons, including yourself, living in the home *
Your answer
List the names, ages and incomes of all person living in your home (including Social Security, SSI, pensions, TANF, VA benefits, etc.). *
Your answer
Individually list the approximate value of all other resources (including other property, boats, cars, checking and/or savings accounts, stocks, bonds, CD's, etc.). *
Your answer
If you have family members who are able to assist in making repairs, please list names and phone numbers *
Your answer
Please explain any financial reasons that prevent you from being able to afford paying for the repairs to your home (list monthly expenses and total amount owed on any loans, car payments, and/or medical bills). *
Your answer
Please list any medical problems or disabilities that prevent you from completing the needed repairs to your home *
Your answer
List the most necessary work needed in order to make your home warm, weatherproof and safe *
Your answer
Check if you currently receive or have ever received assistance from any of these agencies: *
Required
Please list any other agencies you currently or have received assistance from *
Your answer
My signature below indicates that the information provided in this application is accurate and complete; that I am willing to provide additional proof of the claims stated in this application; that I give permission for rebuilding Together Harrisonburg/Rockingham County volunteers and staff to inspect my home for the purposes of home selection and/or repair; and that I consent to the above checked agencies releasing information regarding me to Rebuilding Together. *
Your answer
A copy of your responses will be emailed to the address you provided.
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