Application

Download a PDF version of this application here.

Application

Home Owner Name *

First

Last

Social Security Number *

Birthdate *

Co-Owner Name (if any)

First

Last

Social Security Number

Birthdate

Address *

Phone Number *

Email Address *

Beginning with yourself, list every person living in your household and the information requested. *

Please list each person's name, birthdate, gross monthly income*, source of income**, and relationship to the owner. Required documentation: Please turn in copies of your Income documentation for ALL sources of income and copy of a picture ID for all household members age 16 and older. If 15 or younger please bring their Birth Certificate. Missing Documentation will delay processing of application. *Gross Monthly Income is total income before taxes or other items are deducted. **Sources of income include but are not limited to employment, retirement/pensions, Social Security, SSI, Disability, VA Benefits, etc.

Is the homeowner or anyone else residing in the home disabled? *

If yes, please list the disability

Is the homeowner or anyone else residing in the home a veteran of the Armed Services? *

Service Branch

Dates of Service

Are you a U.S. Citizen? (Owner) *

If not, are you a permanent resident alien? (Owner)

Alien Registration Number (Owner)

Are you a U.S. Citizen? (Co-Owner or Spouse)

If not, are you a permanent resident alien? (Co-Owner or Spouse)

Alien Registration Number (Co-Owner or Spouse)

What type of residence do you own? *

If you own a Mobile Home, Do you own or rent your land?

Do you own any other residential real estate? *

Mortgage Information: Name(s) that appear on the Title-Deed *

Mortgage Company Name *

Original Mortgage Amount *

Approximate Balance *

Account Number *

Mortgage Monthly Payment *

Are Taxes and Insurance included? *

Is your mortgage current? *

Has your home been repaired in the past with funding from a City, County, State, or Federal Grant? *

If yes, please provide the date and the cost of the repair

Have you had a foreclosure? *

Have you declared bankruptcy? *

Are there any liens on the property? *

Do you have any outstanding judgments? *

Explain any YES answers to the previous four questions.

Are the property taxes current? *

Do you have flood insurance? *

Do you have Homeowner’s Insurance? *

Insurance Company Name

Insurance Company Address

Amount of Premium

Coverage Amount

Expiration Date of Policy

Insurance Agent's Name

Insurance Agent's Phone Number

Please provide a detailed description of repairs you would like completed, along with the reasons as to why you need assistance: *

Qualifying Applicants are those who meet the following requirements: Own the home that is to be repaired, Reside in a home needing repair, Demonstrate a legitimate need, Unable to perform the work yourselves, Plan to reside in the home for at least two more years.

If there is a code compliance issue, when is your hearing date:

Credit Check and Verifications: I/we understand and agree that Caring Hands will verify all information contained in this application and check my/our credit through a national credit bureau. *

House Evaluation: I/we understand that Caring Hands will conduct a feasibility assessment of my/our property for the purpose of determining whether my/our home is eligible to receive assistance. I/we understand that Caring Hands has maximum limits that can be spent to repair my/our home. If my/our home cannot be repaired within the maximum dollar limited allowance, I/we will not be eligible for repair. *

Media Release: I/we hereby give my consent for Caring Hands of Deerfield to use and publish my name, photography and/or case history in different media, including television spots, radio announcements, newspaper articles and advertisements, printed materials, posters, websites and other forms of written and digital communication. I/we hereby waive any right that I/we may have to inspect or approve the finished product that may be used in connection herewith.

By stating yes below, I certify that all information is true and correct to the best of my knowledge. *

How did you hear about Caring Hands of Deerfield? *

Phone