Section 1: Homeowner Information

    Name(s) of Homeowner

    Referred by



    Postal / Zip Code

    Home Phone

    Cell Phone

    State / Province / Region


    Work Phone


    Homeowner Birth Date

    Primary Language

    Select Ethnicity

    Section 2: Property Information

    Type of Home

    Do you live in a mobile home?

    Number of Bedrooms

    Is your home on Columbia Association assessed property

    Number of Bathrooms

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

    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)?

    Is anyone in the home a veteran?

    Section 4: Applicant History

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

    Has Rebuilding Together ever done work on your home?

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

    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

    Interior painting

    Roof repairs


    Carpentry repairs

    Wheelchair ramp, grab bars, etc.

    Exterior Painting

    Floor repairs


    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.