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.) |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

|3. PRESENT HOUSING CONDITIONS |

|Describe your present housing: |

| |

|[ ] Own [ ] Rent |

|If you rent, please list your landlord: |

|Address: |

| |

| |

|Phone Number: |

|Do you have permission to do home repair or weatherization? |

| |

|What is the condition of the home that you live in now? |

| |

|[ ] Good [ ] Fair [ ] Bad |

|What kind of problems does your home have? |

| |

| |

| |

| |

| |

| |

| |

|4. HOME REPAIR INFORMATION |

|List the repairs that you would like to have completed: |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|5. WEATHERIZATION INFORMATION |

|Main source of heating: |

| |

|Number of exterior wall outlets in the home: |Number of exterior doors: |

| | |

|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___ | |

| | |

|_____X_____ window (# of windows this size)_______ | |

| | |

|_____X_____ window (# of windows this size)_______ | |

| | |

|_____X_____ window (# of windows this size)_______ | |

| | |

|_____X_____ window (# of windows this size)_______ | |

| | |

|_____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? |

| |

| |

| |

| |

| |

| |

| |

|6. INCOME |

|Include food stamps, TANF, social security, SSI, disability, alimony, child support, pensions, etc. |

|Name |Type of Support |Monthly Amount |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

|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. |

| |

|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. |

| |

| |

| |

|Applicant Signature:________________________________________________ |

| |

|Date:_____________________ |

| |

| |

| |

|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. |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|9. INFORMATION TO BE SUBMITTED |

| |

|Incomplete applications will not be considered. Please submit the following information with your application, as soon as possible: |

| |

|Proof of ownership (i.e. deed, or title) |

|Proof of income for everyone in the household |

|Proof of expenses (i.e. utility bills, etc.) |

| |

| |

|Please send or deliver all required documentation to the Settlement House at: |

| |

|Mail: Scott’s Run Settlement House |

|P O Box 590 |

|Pursglove, WV 26456 |

| |

|Fax: (304) 599-5020 |

| |

|Deliver in person: Monday-Friday, 9am-4pm |

| |

| |

|10. FOR OFFICE USE ONLY – DO NOT WRITE IN THIS SPACE |

| |

|Date received: |

| |

|More information requested: [ ] Yes [ ] No |

| |

|Date of initial home visit: |

| |

|Date of post-home visit: |

| |

|[ ] Approved [ ] Denied (explanation to be part of applicant file) |

| |

|Date approval/Denial letter sent: |

|11. LIABILITY RELEASE |

| |

| |

|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.|

| |

| |

|Home Owner Printed Name: ___________________________________________________ |

| |

|Home Owner Signature:_______________________________________________________ |

| |

|Date:_____________________ |

| |

| |

|SRSH Representative Printed Name: ____________________________________________ |

| |

|SRSH Representative Signature: ________________________________________________ |

| |

|Date: _____________________ |

| |

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download