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A Brush With Kindness Application

We appreciate your interest in our A Brush With Kindness program. Please read each question carefully and answer honestly.

Some sections contain duplicate areas for applicant and co-applicant, so pay careful attention to your entries.

Your application will be reviewed and someone will be in contact with you as soon as possible.

CONTACT INFORMATION

Applicant

Name

*

First Name

Last Name

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Phone Number

*

Email

Verify Email

Social Security Number

Date of Birth

*

Co-Applicant

Name

*

First Name

Last Name

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Phone Number

*

Email

Verify Email

Social Security Number

Date of Birth

*

Provide information for DEPENDENTS or any individuals in your household not listed above.

Name - Age - Gender - SSN (if over 18)

To be considered for Habitat’s ABWK home preservation program you and your family must be willing to complete a certain number of “sweat-equity” hours. Your help in revitalizing your home and the homes of others is called “sweat-equity” and may include clearing the lot, painting, helping with construction, or other approved activities.

I am willing to complete the required sweat equity hours.

*

Check "yes" if you (applicant and co-applicant) agree.

Yes

No

CURRENT HOUSING INFORMATION

If yes, how much are you paying MONTHLY for your mortgage?

How much do you owe on your mortgage?

Who is the lienholder/bank of your current mortgage?

If yes, how much are you currently paying for your insurance?

Please note if this is monthly, quarterly, annually, etc.

Who is your current insurance provider?

Exterior Problem Areas

*

Please select from the following options to indicate where repairs are needed.

Exterior painting

Carpentry repairs on roofing, siding, doors, windows

Tree trimming and removal

Safety and accessibility modifications (ramps and handrails)

General cleaning (does not include regular lawn care or snow removal)

None of the above

EMPLOYMENT INFORMATION AND OTHER INCOME

Applicant

Organization/Employer

Phone

Total years with this employer

Monthly Gross Wage Amount

Other Monthly Income

Please list sources and the amount.

Co-Applicant

Organization/Employer

Phone

Total years with this employer

Monthly Gross Wage Amount

Other Monthly Income

Please list sources and the amount.

DEBT INFORMATION

Applicant

Motor Vehicle

Monthly Payment & Unpaid Balance

Furniture (includes rent-to-own)

Monthly Payment & Unpaid Balance

Alimony

Monthly Payment & Unpaid Balance

Child Support

Monthly Payment & Unpaid Balance

Credit Card

Monthly Payment & Unpaid Balance

Credit Card

Monthly Payment & Unpaid Balance

Credit Card

Monthly Payment & Unpaid Balance

Total Medical

Monthly Payment & Unpaid Balance

Other

Monthly Payment & Unpaid Balance

Other

Monthly Payment & Unpaid Balance

Other

Monthly Payment & Unpaid Balance

TOTAL

Monthly Payment & Unpaid Balance

Co-Applicant

Motor Vehicle

Monthly Payment & Unpaid Balance

Furniture (includes rent-to-own)

Monthly Payment & Unpaid Balance

Alimony

Monthly Payment & Unpaid Balance

Child Support

Monthly Payment & Unpaid Balance

Credit Card

Monthly Payment & Unpaid Balance

Credit Card

Monthly Payment & Unpaid Balance

Credit Card

Monthly Payment & Unpaid Balance

Total Medical

Monthly Payment & Unpaid Balance

Other

Monthly Payment & Unpaid Balance

Other

Monthly Payment & Unpaid Balance

Other

Monthly Payment & Unpaid Balance

TOTAL

Monthly Payment & Unpaid Balance

ASSET INFORMATION

Please complete a different entry for each asset.

Applicant

Name of bank, savings, loan, credit union, etc.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Account Number

Current Balance

Name of bank, savings, loan, credit union, etc.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Account Number

Current Balance

Name of bank, savings, loan, credit union, etc.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Account Number

Current Balance

Name of bank, savings, loan, credit union, etc.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Account Number

Current Balance

Name of bank, savings, loan, credit union, etc.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Account Number

Current Balance

Co-Applicant

Name of bank, savings, loan, credit union, etc.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Account Number

Current Balance

Name of bank, savings, loan, credit union, etc.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Account Number

Current Balance

Name of bank, savings, loan, credit union, etc.

Address

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Account Number

Current Balance

DECLARATIONS

Please answer the following questions.

Applicant

If you answered YES to any question A through E or NO to question F, please explain.

Co-Applicant

If you answered YES to any question A through E or NO to question F, please explain.

AUTHORIZATION AND RELEASE

I understand by filling this application, I am authorizing Habitat for Humanity to evaluate my actual need for the A Brush with Kindness home preservation program, and my willingness to be a partner through sweat equity. I understand that the evaluation will include personal visits, a credit check and employment verification may be denied, and that even if I have already been selected to receive home repairs through A Brush with Kindness program, I may be disqualified from the program. The original copy of this application will be retained by Habitat for Humanity even if the application is not approved.

I also understand that Habitat for Humanity screens all applicant families on the sex offender registry. By completing this application, I am submitting myself to such an inquiry. I further understand that by completing this application I am submitting myself to a criminal background check.

Applicant Signature

*

Enter first and last name.

Date

*

Co-Applicant Signature

Enter first and last name.

Date