Home Repair Online Application

Name of Homeowner *

Age

Place of Employment *

Primary Language Spoken: *

Will translation be necessary?

Yes

No

Ethnicity Ethnicity

Address - Frederick County Maryland residents only *

Address - Frederick County Maryland residents only

Street Address

Apt/Unit

City

State/Province

Zip/Postal

Country

Neighborhood

Phone Number *

Cell Phone

Phone Number

Home

Email

Number of Years at Address: *

Are you a veteran? *

Yes

No

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 * Applicant Living Situation

Is the homeowner, or anyone living in the home, disabled? *

Yes

No

Indicate type of disability:Indicate type of disability:

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. *

Yes

No

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? *

Yes, monthly payment:Yes, monthly payment:

No

Which most resembles the size of your house? *

What is the square footage of your house? *

What year was your home built? *

What year did you purchase your house? *

Exterior of house *

Which most resembles the type of your house? *

Single Family

Duplex

Townhouse

OtherOther

Have you applied to Habitat for Humanity for home repairs in the past? *

No

Yes. What year and what was the result?Yes. What year and what was the result?

Have you had work done at your home by another organization? *

No

Yes. Who and what year?Yes. Who and what year?

Where did you learn about our home repair program? *

If Habitat for Humanity selectes your house for repairs: *

I give permission to be photographed on the day(s) of repair

I give permission to have my name & photo in the media

I am willing to be interviewed by the media about the repairs

Briefly describe the type of work you need done to your home. Possible areas of repair are accessibility modification, carpentry repairs, repair painting, doors and windows, yard 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 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 lived in this house at least 1 year and it was not bought as an "as is". I have no intention to flip, move or offer my home for sale or rent out 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 Habitat Home Repair Program 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 the HHRP makes no warranties, express or implied, regarding any materials used or work done by anyone at my house. I hereby release HHRP, Habitat for Humanity of Frederick County, MD and all associated with it from any and all liability whatsoever. *

I agree to the terms above.

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.

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24 S. Wisner Street, Suite 130

Frederick, MD 21701

301-698-2449