Date Received:
							(for office use only)
Rebuilding Together Worcester Homeowner's Application

Please check one: Mr. & Mrs. Mr. Mrs. Ms.
Name:
Address:					TelNo:
City:				St:		Zip:
Age of Applicant(s):		/

Are you employed? Yes No	IF yes, who is your employer?
Please list everyone, other than the applicant(s) who lives in the house:		(Use additional space if necessary)

NAME	AGE	RELATIONSHIP	EMPLOYED? / EMPLOYER

TOTAL HOUSEHOLD INCOME:	$		/mo.	(Include income of all people except renters living in the house
		(Gross amount)
Please provide proof of income for everyone living in the home (e.g. copy of last year's tax return, determination letter, paycheck stub, etc.).

PROPERTY INFORMATION:    Do you own your home? Yes No
	Number of bedrooms:		Number of bathrooms:
Do you have homeowner's insurance? Yes No    (This is required for participation in Rebuilding Together Worcester)
Homeowner's Insurance Company:
Homeowner's Insurance Policy number:

REPAIR WISH LIST - What are the four most important repairs you need at your home?
1.		3.
2.		4.

Please give any information about yourself that will be important for us to consider in evaluation your application (e.g. medical conditions, etc.) and let us know how the repairs you have listed will help you:
If your home is selected, we expect able-bodied family and friends to help on Friday-Sunday, April 18-20, 2008.
Will this happen? Yes No	If no, why?
I/we certify that the above information is true and correct to the best of my/our knowledge. I/we realize that failure to provide all information requested could result in our application being invalid. I/we authorize you to check any references necessary to complete the processing of this application for the purpose of receiving housing rehabilitation through Rebuilding Together - Worcester. I/we also understand that any information received will be kept confidential and will be used strictly for determining my/our eligibility for this program.

Signature(s) of Homeowner(s)		Date
Referred by:		Phone:
Return to: Rebuilding Together Worcester P.O. Box 2774 Worcester, MA 01613