Name of Homeowner
Occupation or Place of Employment
Primary Language Spoken:
Will translation be necessary?
American Indian or Alaska Native
Black or African American
Native Hawaiian or Pacific Islander
Choose Not to Answer
Antigua and Barbuda
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Cocos (Keeling) Islands
Falkland Islands (Malvinas)
French Southern Territories
Heard Island and McDonald Islands
Isle of Man
Northern Mariana Islands
Papua New Guinea
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Sint Maarten (Dutch part)
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Trinidad and Tobago
Turks and Caicos Islands
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Number of Years at Address:
If you are a veteran, are you receiving any Veterans Benefits? (Pension, Disability, etc). If so, please describe:
List the names, ages and relationship to homeowner of all people living in the home:
Applicant Living Situation
Lives with parents/relatives/friends
Applicant Living Situation
Is the homeowner, or anyone living in the home, disabled?
If your application is a more appropriate fit with other, similar programs, may we share it with them? Unless you give us permission to share your information with other organizations, it will be kept confidential. If you check yes, you give Habitat for Humanity your consent to share the information you provided on this application with similar organizations.
What is the total, combined income before taxes for ALL persons living in the home per year?
Are you still making loan payments on your house?
Which most resembles the size of your house?
What is the square footage of your house?
What year was your home built?
What year was your home purchased?
Which most resembles the type of your house?
Have you applied to Habitat for Humanity for home repairs in the past?
Have you had work done at your home by another organization?
Where did you learn about our home repair program?
If Habitat for Humanity selectes your house for repairs:
Briefly describe the type of work you need done to your home. Possible areas of repair are accessibility modification, carpentry repairs, roofing repairs, painting, doors and windows, general cleaning, plumbing, electrical repairs, etc. The items listed below will all be considered for repair, but the final decision on what work can be done with our time and resources will be made at the descretion of Habitat for Humanity and our committees. The work done will focus on warmth, safety and independence. Our volunteers are NOT professionals and may not be able to make all repairs.
Personal Statement. If there is anything else you would like to share with us about your home or story, please use the space below.
Homeowner's Agreement. By checking below, I certify that the information on this application is accurate and that I own the property and am primary resident at the address given on this application. I have no present intention to move or offer my home for sale for at least 3 years. I confirm that any physically able person residing in my home or visiting for the project that day will work alongside the A Brush With Kindness volunteers. I confirm that, except for the condition listed above, my home is a safe place for volunteers. To the extent permitted by law and without affecting the coverage provided by the required homeowner insurance, I waive any rights it may have to recover against Habitat for Humanity of Frederick County, MD and its programs for (1) damages for injury or death to persons or (2) damages to property for claims arising from such damages. This waiver is fully intended to waive fully, for the benefit of Habitat for Humanity of Frederick County, MD, any rights and/or claims, which might rise to a right of subrogation. I understand that the people who may work on my house are unpaid volunteers; that few, if any of them, are skilled in the building trades; and that A Brush With Kindness makes no warranties, express or implied, regarding any materials used or work done by anyone at my house. I hereby release A Brush With Kindness, Habitat for Humanity of Frederick County, MD and all associated with it from any and all liability whatsoever.
If you are not the homeowner, but are assisting the homeowner in completeing the application, please provide your name, contact information and relationship to the homeowner in the box below.
If you are human, leave this field blank.