List the names of all of people who live in your home ...
I am applying for: (please check one)
Home Repair _____ Weatherization _____ Both _____
|1. APPLICANT INFORMATION |
|Name |
|Address |
|City |State |Zip Code |
|Home Phone |Alternate Phone |Date of Birth |
|Spouse’s Name |
|LIST THE NAMES OF ALL PEOPLE LIVING IN YOUR HOME, |
|INCLUDING YOURSELF |
|Full Name |Age |Relationship |
| | |(Son/daughter/etc.) |
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|3. PRESENT HOUSING CONDITIONS |
|Describe your present housing: |
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|[ ] Own [ ] Rent |
|If you rent, please list your landlord: |
|Address: |
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|Phone Number: |
|Do you have permission to do home repair or weatherization? |
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|What is the condition of the home that you live in now? |
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|[ ] Good [ ] Fair [ ] Bad |
|What kind of problems does your home have? |
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|4. HOME REPAIR INFORMATION |
|List the repairs that you would like to have completed: |
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|5. WEATHERIZATION INFORMATION |
|Main source of heating: |
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|Number of exterior wall outlets in the home: |Number of exterior doors: |
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|List the size of each window in your home |Do you have a hot water tank that needs to be covered? |
|(width and height in inches): | |
| |( ) yes ( ) no |
|For example, if you have 2 windows that measure 36 inches wide and are 80 inches| |
|tall, you’d fill in: | |
|___36___X___80___ window (# this size) ___2___ | |
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|_____X_____ window (# of windows this size)_______ | |
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|_____X_____ window (# of windows this size)_______ | |
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|_____X_____ window (# of windows this size)_______ | |
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|_____X_____ window (# of windows this size)_______ | |
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|_____X_____ window (# of windows this size)_______ | |
| |Are there any water pipes that are exposed to the weather? |
| |( ) yes ( ) no |
| |If yes, where are they located? |
|Are there any other weatherization concerns that you would like to have addressed? |
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|6. INCOME |
|Include food stamps, TANF, social security, SSI, disability, alimony, child support, pensions, etc. |
|Name |Type of Support |Monthly Amount |
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|7. AUTHORIZATION AND RELEASE |
|I understand that by filing this application, I am authorizing Scott’s Run Settlement House, Inc. to evaluate my actual need for home repair |
|and/or weatherization, and my ability to afford expenses of homeownership. I understand that the evaluation may include personal visits, |
|income verification, and employment verification. I have answered all the questions on this application truthfully. I understand that if I |
|have not answered the questions truthfully, my application will be denied, and that even if I have already been selected to receive |
|assistance, I will be disqualified from the program. |
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|Scott’s Run Settlement House will retain the original copy of this application even if my application is not approved. If I am approved, I |
|acknowledge that I must sign a liability release in order for services to be rendered. |
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|Applicant Signature:________________________________________________ |
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|Date:_____________________ |
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|Please Note: If more space is needed to complete any part of this application, please use a separate sheet of paper and attach it to this |
|application. |
|8. DIRECTIONS/QUESTIONS/MISCELLANEOUS |
|In the space below, please write detailed directions to your home. Also, if you have any questions or concerns, please feel free to write |
|those in below. |
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|9. INFORMATION TO BE SUBMITTED |
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|Incomplete applications will not be considered. Please submit the following information with your application, as soon as possible: |
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|Proof of ownership (i.e. deed, or title) |
|Proof of income for everyone in the household |
|Proof of expenses (i.e. utility bills, etc.) |
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|Please send or deliver all required documentation to the Settlement House at: |
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|Mail: Scott’s Run Settlement House |
|P O Box 590 |
|Pursglove, WV 26456 |
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|Fax: (304) 599-5020 |
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|Deliver in person: Monday-Friday, 9am-4pm |
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|10. FOR OFFICE USE ONLY – DO NOT WRITE IN THIS SPACE |
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|Date received: |
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|More information requested: [ ] Yes [ ] No |
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|Date of initial home visit: |
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|Date of post-home visit: |
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|[ ] Approved [ ] Denied (explanation to be part of applicant file) |
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|Date approval/Denial letter sent: |
|11. LIABILITY RELEASE |
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|I hereby waive any right or cause of action arising as a result of my participation in the Home Repair and Weatherization Program from which |
|any liability may or could accrue against Scott’s Run Settlement House (SRSH) or its officers, directors, employees, assigns, and/or |
|successors in interest, collectively or individually. The work is done by staff and/or volunteers and is without warrant or guarantee. SRSH |
|is obligated to finish only the tasks that are started by its staff and/or volunteers. Neither SRSH, nor its staff and/or volunteers, will be|
|held liable for work not completed to homeowner’s satisfaction. I agree that this waiver shall include any rights or causes of action |
|resulting from personal injury to me or damage to my property in connection with my activities in the Home Repair and Weatherization Program.|
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|Home Owner Printed Name: ___________________________________________________ |
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|Home Owner Signature:_______________________________________________________ |
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|Date:_____________________ |
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|SRSH Representative Printed Name: ____________________________________________ |
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|SRSH Representative Signature: ________________________________________________ |
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|Date: _____________________ |
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