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Rebuilding Together repairs and rehabilitates homes every year in April using groups of community volunteers. This organization assists homeowners who have safety issues, weatherization, or accessibility concerns in their homes by making necessary repairs or modifications.
The work is done at no cost to the property owner, but family members are encouraged to participate to the best of their ability. This year Rebuilding Together of Harrisonburg/Rockingham County repaired seventeen area homes in its sixth year of operation.
The project selection committee seeks applications from agencies and groups that serve low-income individuals and families, particularly elderly, persons with disabilities, or persons with impaired health.
An eligibility application is below...Feel free to make additional copies of the application. Applications should be sent to: PO Box 2301, Harrisonburg, VA 22801. The deadline for the April 2006 workdays is January 15, 2007. This is a firm deadline so that adequate plans can be made for organizing volunteers. |
PRINT & CLIP HERE for APPLICATION FORM
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Harrisonburg/Rockingham County
A non-sectarian, non-profit organization working in partnership with communities across
America to deliver home rehabilitation services to low-income, elderly, and disabled homeowners.
P.O. Box 2301 ? Harrisonburg, VA 22801? (540) 830-7759
ELIGIBILITY APPLICATION
(Please print or type)
Name of Applicant
Address
Directions to Home ______________________________________________________________
______________________________________________________________________________
Phone # (H) (540)___________________(W) (___)
Age of Applicant _______
Check if Self-Referral £
Agency Making Referral _______________________ Phone #
Agency Representative
Agency Mailing Address
Do you own your home? £ Yes £ No (if no, we are unable to assist you)
Is there a mortgage? £ Yes £ No List monthly amount $________
Are all real estate taxes paid? £ Yes £ No
Number of persons, including yourself, living in your home
List names, ages, and income of all persons living in your home (include Social Security, SSI, Pensions, TANF, VA Benefits, etc.).
__________________________________________________________________
1) Name Age Income (per month) Source
__________________________________________________________________
2) Name Age Income (per month) Source
__________________________________________________________________
3) Name Age Income (per month) Source
__________________________________________________________________
4) Name Age Income (per month) Source
Individually list the approximate value of all other resources (including other property, checking and/or savings accounts, stocks, bonds, CD's, etc.) __________________
If you have family members who are able to assist in making repairs, please list names and phone numbers ____________________________________________________________________________________
Please explain any financial reasons that prevent you from being able to afford paying for the repairs to your home (please list monthly expenses and total amount owed on any loans, car payments, and/or medical bills, etc.)
____________________________
Please list any medical problems or disabilities that prevent you from completing the needed repairs to your home________________________________________________________________________________
____________________________________________________________________________________
List the most necessary work needed in order to make your home warm, weatherproof, and safe
____________________________________________________
Check if you currently receive or have ever received assistance from any of these agencies:
£ Rockingham Free Clinic
£ Hospice
£ Home Health (specify agency)_____________
£ Community Services Board
£ Department of Rehabilitative Services
£ Health Department
£ Valley Association for Independent Living
£ Social Services
£ Area Food Banks
£ Redevelopment and Housing Authority
£ Weatherization
£ Salvation Army
£ Valley Program for Aging
£ Elkton Area United Services
£ Blue Ridge Legal Services
£ ParaTransit
£ Rockingham County Transportation Program
£ Area Church(es)
£ People Helping People
Please list other agencies:_________________________________________________________
____________________________________________________________________________
My signature below indicates that the information provided in this application is accurate and complete; that I am willing to provide additional proof of the claims stated in this application; that I give permission for Rebuilding Together Harrisonburg/Rockingham County volunteers and staff to inspect my home for the purposes of home selection and/or repair; and that I consent to the above checked agencies releasing information regarding me to Rebuilding Together.
_______________________________________ ________________________
Signature of Applicant Date of application
(For office use only)
Date of initial call for services ___________________
Date application was mailed
Date application was received ___________________
Previewer-Name Telephone
Workscope-Name Telephone
Disposition of Application
Date Applicant Notified
If approved, starting date Date Completed
House Captain Name Telephone |