2018 Applicaton and letter

30 S. Main Street Suite B Dayton OH 45402 937.223.4893 www.rtdayton.org

Dear Homeowner: We understand your home is in need of some modifications/repairs. We would like to invite you to complete the application and return it to our office via post mail with your 2018 income documentation.

To prevent delays with your application, RTD requires the following information: -

-

Application filled out completely Proof of gross income for all residents living in the home, such as: o Recent (2018) Social Security benefits statement o 2 consecutive paychecks with Year to Date included o Pension statements We do not accept bank statements as proof of income.

Send all information to:

Rebuilding Together Dayton 30 South Main St., Suite B Dayton, OH 45402

Please Note: Submitting an application does not guarantee that services will be provided. Do not submit this application without 2018 proof of income.

Sincerely, Rebuilding Together Dayton

The Miami Valley’s leading organization dedicated to safe and healthy housing

Rebuilding Together Dayton 2018 Homeowner Application

Return via post mail with PROOF OF INCOME to 30 S. Main Street, Suite B Dayton, OH 45402

HOMEOWNER INFORMATION Homeowner 1 Name:

Homeowner 2 Name:

 Married  Widowed  Single

 Married  Widowed  Single

 Male

 Male

 Female

Date of Birth:

Are you physically challenged?  Yes If yes, please describe:

 No

 Female

Date of Birth:

Are you physically challenged?  Yes If yes, please describe:

 No

PROPERTY INFORMATION Address:

Zip Code:

Do you live in the home?  Yes

 No

What year did you move into the home?

Home Phone Number:

Cell Phone Number:

Have you missed a mortgage payment in the last year?  Yes  No Do you own other/rental property?  Yes  No

How many have you missed?

If yes, please describe:

REPAIRS NEEDED  Grab bars

 Handrails

 Step-in shower

 Tall Toilet

 Ramp

 Electrical

 Plumbing

 Furnace

 Water Heater

 Other:

WE CANNOT ASSIST WITH: Roofs Weatherization/windows General maintenance/yardwork

HOUSEHOLD INFORMATION List Information for EACH resident, including the homeowners.

List the name and ages of all people living in the home (attach a list if more space is needed).

Name: _________________________ Age: ___ Physically challenged: Y / N Relationship: __________________ M / F Name: _________________________ Age: ___ Physically challenged: Y / N Relationship: __________________ M / F Name: _________________________ Age: ___ Physically challenged: Y / N Relationship: __________________ M / F Name: _________________________ Age: ___ Physically challenged: Y / N Relationship: __________________ M / F Are any adults in the home employed?  Yes  No

Total number of residents receiving ANY income: ____

Has anyone in the home recently fallen?  Yes  No

Does anyone in the home have asthma?  Yes  No

Who can we call if we cannot reach you?

Name:

Race Disclosure

Relationship: Homeowner 1

Phone Number:

Homeowner 2

For office use only v 10.13.17

White

Age

Year Built

Black American Indian or Alaskan Native Hispanic Asian or Pacific Islander Other / Multi-racial

FPG% AMI % Disabled # Years Veteran

Sq. Ft. Monthly Annual Taxes Due Referral:

Ethnicity Disclosure

Homeowner 1

Homeowner 2

Hispanic

Yes / No

Yes / No

S of Vet

SOCIAL SERVICES Do you have a social worker?  Yes Social worker’s agency:

 No

Social worker’s name: Social worker’s phone number:

Are you a veteran?  Yes  No Are you a spouse of a veteran?  Yes  No Who referred you to us?  Area Agency on Aging  Senior Resource Connection  County Corp  Housing Inspector  Catholic Social Services  East End Community Center  CityWide  Meals on Wheels  Wesley Community Center  Community Action Partnership  Neighbor  Case Manager  Other:

INCOME AND EXPENSES Your application must include the total gross income (amount before taxes) from EACH resident in the home.

Include documentation, such as Social Security benefit letters, pay stubs, or pension benefit letters.

NOTE: Bank statements are NOT accepted as proof of income.

MONTHLY INCOME INFORMATION Salary (monthly total before taxes) $ Social Security/Disability $ Social Security/Disability $ Child Support/Alimony $ SNAP Benefits $ Other: $ Other: $

MONTHLY EXPENSE INFORMATION Mortgage payment/taxes $ Home insurance $ Utilities (Gas and Electric) $ Water/Sewer Services $ Telephone $ Cable/internet $ Medical $

TOTAL MONTHLY INCOME:

TOTAL MONTHLY EXPENSES:

$

$

WARNING!! It is a Federal crime punishable by fine and/or imprisonment, to knowingly make false statements concerning any of the above facts as applicable under the provisions of Title 18, US Code, Section 1014.

IMPORTANT – READ CAREFULLY and SIGN AT THE BOTTOM: By signing below, I certify that I do not have the financial means (savings, investments, etc.) to perform the repairs for which I am applying. I certify that the above statements are true, accurate, and complete to the best of my knowledge and belief. This application shall remain the property of Rebuilding Together Dayton, to which it is submitted for the purpose of obtaining assistance. I hereby consent to and authorize Rebuilding Together Dayton, after providing me reasonable notice, to enter the property for the purpose of determining the need and scope of the repair(s) specified above. I authorize the disclosure of the above information to only those persons or agencies as necessary to secure the assistance for which this application is submitted. I hereby consent to the unrestricted use of my image and that of my family members, in connection with the Project, by Rebuilding Together Dayton or any person authorized by Rebuilding Together Dayton, including, but not limited to, any photographs, audio or video recordings, interviews, videotapes, motion pictures or the use of my name in connection with television, radio or print media. I understand that the submission of this application and any subsequent home assessments do not guarantee any repairs will be completed and any repairs to be completed will be dependent upon the funding available.

Homeowner 1 Signature

Date

Homeowner 2 Signature

Date

Please return this application with proof of income documentation to: Rebuilding Together Dayton 30 S. Main St. Suite B, Dayton OH 45402 Proof of income documentation CANNOT be a bank statement. We accept pension/social security benefit letters, paystubs, and SNAP/child support documentation.