Home Repair Application Form

If you need any assistance completing this application, we would be happy to help you, simply stop by our office or call 419.481.8100

In order for us to process your application, you will need to submit the following supporting documentation:

Picture ID (front and back) for every adult living in the home.
Last 8 consecutive weeks of pay stubs for every adult working in the home.
Recent bank statements: 6 months of checking and 2 months of savings statements for every adult living in the home.
Documentation of all other household income (e.g. social security, disability, food stamps, and child support).
Complete the Assets Certification Form by clicking HERE
Complete Certification of Zero Income Form (if applicable) by clicking HERE

Click here to submit your supporting documents

Applicant Information:

Applicant Name

First Name *

Middle *

Last Name *

Applicant Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

County (Required)

Applicant Email Address (Required)

Applicant Date of Birth

Month

Day

Year

Phone (Required)

Applicant Phone Number

Ethnicity

Hispanic or Latino
Not Hispanic or Latino

Race

White
Black or African American
American Indian or Alaskan Native
Asian
Native Hawaiian or Pacific Islander
Other

Do you own your home?

Monthly Payment $ (Required)

Year Purchased (Required)

Are you a U.S. Citizen or Permanent Resident?

Are you a veteran or active member of the U.S. military?

Military branch

Are you affiliated with an organization/faith-based group who would be willing to volunteer on this project?

If Yes, what group?

Applicant Employment Information

Applicant Current Employer, if applicable

Position, if applicable

Applicant Employer Address, if applicable

Applicant Employer Address

Length of time in position, if applicable

Phone, if applicable

Employer phone number

Co-Applicant Information, if applicable

Co-Applicant Name

First Name

Last Name

Relationship to Applicant

Co-Applicant date of birth

Month

Day

Year

phone

Co-Applicant phone number

Is Co-Applicant a U.S. citizen or permanent resident?

Is Co-Applicant a veteran or active member of the U.S. military?

Military branch?

Co-Applicant Employment Information:

Co-Applicant Current Employer, if applicable

Co-Applicant Current Employer Address, if applicable

Position, if applicable

Length of time in position, if applicable

phone, if applicable

Current employer phone number

Total number (Required)

Total number of people living in the home

Dependents:

Name (person 1)

Please list ALL individuals who live in the Applicant Household

Date of Birth (person 1)

Relationshiip (person 1)

Name (person 2)

Date of Birth (person 2)

Relationship (person 2)

Name (person 3)

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Date of Birth (person 3)

Relationship (person 3)

Name (person 4)

Date of Birth (person 4)

Relationship (person 4)

Name (person 5)

Date of Birth (person 5)

Relationship (person 5)

Name (person 6)

Date of Birth (person 6)

Relationship (person 6)

Name (person 7)

Date of Birth (person 7)

Relationship (person 7)

Name (person 8)

Date of Birth (person 8)

Relationship (person 8)

Are any of the dependents above veterans or active members of the US military, or a spouse of a veteran or active member of the US military?

If yes, who?

Monthly Household Income:

Include all sources for applicant, co-applicant, and all adult individuals (18+) listed under dependents.

Applicant Employment Income

Applicant Social Security

Applicant Supplemental Security Income/Disability

Applicant Food Stamps

Applicant Retirement/VA Income

Applicant Child Support Income

Applicant Alimony Income

Applicant TANF Income

Applicant Other Income

Co-Applicant Employment Income

Co-Applicant Social Security

Co-Applicant Supplemental Security Income/Disability

Co-Applicant Food Stamps

Co-Applicant Retirement/VA Income

Co-Applicant Child Support Income

Co-Applicant Alimony Income

Co-Applicant TANF Income

Co-Applicant Other Income

Adult Individuals (18+) Employment Income

Adult Individuals (18+) Social Security

Adult Individuals (18+) Supplemental Security Income/Disability

Adult Individuals (18+) Food Stamps

Adult Individuals (18+) Retirement/VA Income

Adult Individuals (18+) Child Support Income

Adult Individuals (18+) Alimony Income

Adult Individuals (18+) TANF Income

Adult Individuals (18+) Other Income

Monthly Household Expenses:

Mortgage/Lot Rent

Property Tax

Homeowner's Insurance

Gas Bill

Electric Bill

Child Support Paid

Water & Sewer Bill

Garbage Removal

Home Repair Needs:

Please check all that apply to your home repair needs

roof repair or replacement
fascia/gutter repairs
siding and trim repair/replacement
window/door replacement
porch repair/replacement
interior floor/wall repair
minor electrical repair/replace
minor plumbing repair/replace

(Required)

Please describe the nature of the repairs needed

AUTHORIZATION AND RELEASE

Please review and check box below.

I understand that by completing this application, I am authorizing Habitat for Humanity of Wood County Ohio (HFHWC) to:

1) Evaluate my actual need for a home repair

2) Evaluate my ability to repay the loan (if applicable)

3) Evaluate my willingness to partner

I understand that the evaluation will include, but is not limited to: personal visits, a credit check and employment verification. I have answered all of the questions on this application truthfully. I understand that if I have not answered the questions truthfully, my application may be denied, and that even if I have already been selected to receive a home repair, I may be disqualified from the program. The original or a copy of this application will be retained by HFHWC even if the application is not approved.

I understand that I am committing to live in the home for at least two years after completion of the project.

I hereby authorize and instruct HFHWC to obtain and review my credit report and conduct a criminal background check. My credit report and criminal background check will be obtained from consumer reporting agencies chosen by HFHWC. I give permission for other agencies providing services to me/my family to release to HFHWC any and all information HFHWC may request as necessary in processing and determining the amount/type of home repair assistance I will receive. I understand the information will be held in confidence and will be used for the sole purpose of facilitating home repairs.

I understand that I may revoke my consent to these disclosures by notifying HFHWC in writing. You have the right to request that we make complete and accurate disclosure of the nature and scope of the information requested. Such disclosure will be made to you within five (5) days of the date on which we receive a written request from you or within five (5) days of the time the report was first requested, whichever is later. The Fair Credit Reporting Act gives you specific rights in dealing with consumer reporting agencies.

I acknowledge that I may be responsible to pay a down payment of $50 for the repairs, followed by monthly payments at 0% interest.

As part of our agreement, I will be present for the duration of the home repair. Exemptions must be discussed with the HRM construction manager before work begins. As part of our agreement, I will ensure that the exterior and interior areas to be repaired will be clean of trash and objects that may interfere with the repairs.

I will provide drinking water and allow volunteers to use my bathroom. I will also grant permission for volunteers to help with the home repairs.

I authorize
I do not autorize

What We Do

Home Repair Application Form

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