Oct 21, 2016 - 4. Email: ... Please list the name and date of birth for any additional household members/dependents. Nam
ROCK THE BLOCK! Home Preservation – Application Rock the Block is a new effort by Habitat Oakland County to help homeowners in a neighborhood with minor home repairs, landscaping and more! Project Dates: OCTOBER 20th & 21st 2016
HOME INFORMATION: Property Address: ________________________________________________ City: ______________________ State: _______ Zip: ____________
HOUSEHOLD INFORMATION:
Projects are approved on a first come first serve basis. Hurry and submit your application before the program is full!
1. Name:______________________________________________
I am a Military Veteran - branch: ____________
2. Date of Birth: ______/_____/________
I am the surviving spouse of a Military Veteran
3. Phone: __________________________
OPTIONAL: One or more household members has a disability
4. Email: _______________________________________ Please list the name and date of birth for any additional household members/dependents Name(s): _______________________________________________________
Date of Birth: ______/_____/_______
_______________________________________________________
______/_____/_______
_______________________________________________________
______/_____/_______
_______________________________________________________
______/_____/_______
_______________________________________________________
______/_____/_______
Over 18yrs:
ROCK THE BLOCK – HOME REPAIR SERVICES AVAILABLE: My home is in NEED of one or more of the following services: * Services also available to renters Energy Audit to identify savings* Band joist insulation Air Leakage testing, Air sealing Furnace tune-up High efficiency showerhead Water heater pipe wrap High efficiency faucet aerator Carbon monoxide testing Landscape: Rake, edge, trim hedges, level landscape blocks
$ FREE
$10 - $25
Gutter Cleaning, install Gutter Guards
$10-$100 (subject to assessment)
Exterior of Home Painting
$200-$500 (subject to testing & assessment)
Wood porch, steps or fence repair (does not include paint/stain)
$75 -$125 (subject to testing & assessment)
Wood porch or fence painting/stain
$25-$100 (subject to survey & testing)
Dumpster Ditch Day *
$ FREE
PLEASE TURN OVER AND COMPLETE OTHER SIDE Page 1 of 2
PLEASE CHECK ALL THAT APPLY: HOMEOWNERSHIP: I am the legal owner of my home (my name is listed on the property deed) Date Purchased: ___________________ I am NOT the homeowner; I am currently renting the home This home is my primary residence How long have you lived in the home: ________________ ABILITY TO PAY: I understand that Habitat will charge a reasonable fee for the services I am approved for My fee will be reviewed with me and agreed upon prior to project approval My fee is due and shall be paid in full prior to the work day on my home WILLINGNESS TO PARTNER: I will be available and participate in work done at my home alongside Habitat volunteers when scheduled I will put in the required number of sweat equity hours for my project (4-8 hours) I am willing to display partnership materials (lawn sign, stencil)
FINANCIAL INFORMATION: Please list the sources of income for your household. Ex: Job, Social Security, SSD, SSI, Child Support, etc. Please list the amounts BEFORE taxes
Income source: ________________
How often are you paid? (circle one) weekly, bi-weekly, monthly
Amount per check $__________
Income source: ________________
How often are you paid? (circle one) weekly, bi-weekly, monthly
Amount per check $__________
Income source: ________________
How often are you paid? (circle one) weekly, bi-weekly, monthly
Amount per check $__________
Income source: ________________
How often are you paid? (circle one) weekly, bi-weekly, monthly
Amount per check $__________
Income source: ________________
How often are you paid? (circle one) weekly, bi-weekly, monthly
Amount per check $__________
Habitat Oakland County will evaluate your gross household income and determine if it falls within the eligibility guidelines for your household size, not exceeding the current Oakland County Annual Income Guidelines*. *These figures are adjusted annually by the U.S. Dept. of Housing and Urban Development (HUD). Figures are subject to change.
AUTHORIZATION & RELEASE: I understand that by submitting this pre-screening form, I am authorizing Habitat for Humanity of Oakland County (HFHOC) to evaluate my eligibility for home preservation services. I also understand that an evaluation will include a criminal background and sexual offender check. I have answered all the questions on this form truthfully. The original or a copy of this form will be retained by HFHOC even if the application is not approved. HFHOC will not share the information on this application form with any outside agency and your name (s) will not be put on any mailing lists outside this agency. ___________________________________________________________________________________________________ Homeowner Signature Date Return completed application to: Habitat for Humanity of Oakland County - Office
Alternate Drop Off Location: Association President Greg Didierjean’s Home
150 Osmun St, Pontiac, Michigan 48342-3125
28108 Glasgow St, Southfield, MI 48076
Fax: (248) 338-1361
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