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What We Do

Home Repair Application Form

Applicant Information:

First Name
Last Name
Country
Address Line 1
City
State
Postal Code
/
/
Applicant Phone Number
Do you own your home?
Are you a U.S. Citizen or Permanent Resident?
Are you a veteran or active member of the U.S. military?
Are you affiliated with an organization/faith-based group who would be willing to volunteer on this project?

Applicant Employment Information

Country
Address Line 1
City
State
Postal Code
Employer phone number

Applicant Previous Employer Information

Country
Address Line 1
City
State
Postal Code
Previous Employer phone number

Co-Applicant Information:

First Name
Last Name
/
/
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?

Co-Applicant Employment Information:

Country
Address Line 1
City
State
Postal Code
Current employer phone number

Co-Applicant Previous Employer Information

Country
Address Line 1
City
State
Postal Code
Co-Applicant Previous employer phone number

Dependents:

Please list ALL individuals who live in the Applicant Household
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 list home repair needs below

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 a background verification. My credit report and background verification 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 and agree that HFHWC intends to use the credit report for the purpose of evaluating my financial readiness for receiving home repairs. I further understand and agree that HFHWC intends to use the background verification for the purpose of evaluating my character and willingness to partner with HFHWC.

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 for making a down payment on the project and monthly payments afterwards until the loan is paid in full.

As part of my "sweat equity" requirement, I will be present for the duration of the home repair. Exemptions must be discussed with HFHWC before work begins. 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.


Thank you to our generous sponsors.

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