Section 1: Homeowner Information

Name(s) of Homeowner

Referred by

Address

City

Postal / Zip Code

Home Phone

Cell Phone

State / Province / Region

Country

Work Phone

Email

Homeowner Birth Date

Primary Language

Select Ethnicity

Section 2: Property Information

Type of Home

Do you live in a mobile home?
yesno

Number of Bedrooms

Is your home on Columbia Association assessed property
yesno

Number of Bathrooms

Do you have homeowner's covenant violations that need to be corrected?
yesno

Occupant List
List all people living in the home including renters. For each person, please list name/age/male or female/currently employed or not/ and specify if they are a renter...

Total Number of people living in the home

Home owner Insurance carrier

Agent's Name

Policy Number

Agent's Phone

Section 3: Special Needs / Disabilities

Is anyone in the home receiving disability (SSI)?
yesno

Is anyone in the home a veteran?
yesno

Section 4: Applicant History

Have you ever applied to Rebuilding Together Howard County (formerly known as Christmas in April)?
yesno

Has Rebuilding Together ever done work on your home?
yesno

Have you received services from Office on Aging, Community Action Council or other home repair program?
yesno

Section 5: Type of Repairs to be Considered

Please indicate what types of repairs are needed. If yes, then please elaborate where possible.

Electrical repairs
yesno

Interior painting
yesno

Roof repairs
yesno

Plumbing
yesno

Carpentry repairs
yesno

Wheelchair ramp, grab bars, etc.
yesno

Exterior Painting
yesno

Floor repairs
yesno

Other
yesno

Emergency Contact Information
Please list the name and telephone number of a person to contact in an emergency.

Prioritization of repairs
Please list the repairs that you feel need immediate attention in the order as you see it.

Section 6: Verification of Household Income

Verification of Household Income
Rebuilding Together® Howard County serves homeowners who live on a limited income and own their own home, with a special focus on the elderly and disabled. For this reason, we must ask you to certify the total household income for all the people who live within your home and we will verify property ownership.

Special Circumstances
Are there any special circumstances regarding the amount of expenses within your household that we need to be made aware of such as home health care, hospital costs, medication expenses, etc.?

Why do you feel your home should be selected for RTHC?
How will the improvements help you? Please give us any information about yourself that will be important for us to consider in evaluating your application.

Section 7: Terms & Conditions

Terms & Conditions:
I understand that I am applying for, or may be receiving services from, Rebuilding Together® Howard County, Inc. In order to access additional services for which I may be eligible, I grant permission for Rebuilding Together® Howard County, Inc. to share referral information with the agencies listed below, unless stricken through. My confidentiality will be protected by these agencies while permitting the flow of appropriate information among the staff of agencies listed above. I understand that to the extent permitted by law, my records will be treated confidentially. I understand this consent may be revoked by me at any time. Howard County Office on Aging, Howard County Disability Services, Howard County Dept of Social Services, Howard County Consumer Affairs, Howard County Health Department, Howard County Department of Housing, Howard County Office of Children’s Services, Neighbor Ride, Howard County Community Action Counsel. Rebuilding Together also works with congregations that may provide emergency or minor repair work. By checking the box below, I authorize RTHC to contact these congregations on my behalf if the repairs I have requested are more appropriate to the services they offer.