Home Repair Program Request for Assistance

If you hold title to the home with another person, please include their name on this application.

Please include all persons living in the home currently.

Please include the total combined ANNUAL income for all persons living in the home.

1 Occupant - $64,100

2 Occupants - $73.200

3 Occupants - $82,400

4 Occupants - $91,500

5 Occupants - $98,900

6 Occupants - $106,200

7 Occupants - $113,500

8 Occupants - $120,800

Is your name on the Deed? You must be named on the Deed for us to assist you. If your answer is no, you will be required to provide proof of ownership before we can consider your request for assistance.

Your property taxes must be current in order for us to work on your home.

Are there obvious cracks in the foundation under your home (in basement walls, stem walls or concrete blocks under the exterior walls of the house).

For the home qualifying visit, we will need access to every room in the home, and will need to be able to see all sides of the exterior of the home.

Please note: the items listed below will be considered for repair, but the final decision on what work can be completed will be made at the discretion of the WHFH Home Repair Program based on the scope of work and available financial resources. As previously stated, the Home Repair Program focuses on ensuring homes meet Minimum Housing Quality Standards. No cosmetic repairs or those deemed of a luxury nature will be allowed. We also do not work on detached structures of any kind, including fences.

By indicating YES below, I declare that I understand all of the following statements:

The information gathered on this form will be used to start the eligibility review process, and that completing this form in no way guarantees assistance of any kind. Additional information will be required to establish eligibility.

I am authorizing Habitat for Humanity to evaluate my home’s need for repairs under the guidelines of the Home Repair Program. In addition, I am declaring that I have read and understand the following information.

The evaluation will be based on:

1. Need for Repairs: The evaluation process will include a personal visit to determine if the home qualifies for the program. The criteria will be explained in more detail at the qualifying home visit. A second, more detailed scope of work inspection will be completed if the household qualifies based on the Ability to Pay determination as explained below.
2. Willingness to Partner: This will include providing requested documentation in a timely manner and participating in sweat equity, volunteerism, and/or classroom training. The number of sweat equity hours required will be based on the size/scope of the project.
3. Ability to Pay: If the house qualifies for the program, my eligibility will then be evaluated on the ability to qualify for grant funding to cover the repair costs and/or to repay a 0% interest loan. This will require employment and income verification for which I will need to provide the requested documentation.

I will be required to pay a $35 processing fee if I submit an Application after the qualifying home visit. I will be required to pay a fee of $115 if my application is approved and I sign a Partnership Agreement for repair services.

I am declaring to be the sole owner(s) of the property listed at the address given and I have answered all questions truthfully. If it is determined any information provided is not true I may be disqualified from the program, even if I have already been selected to receive assistance.

I understand the original or a copy of this Request for Assistance will be retained by Habitat for Humanity even if the application is not approved.