Rebuilding Together - Oakland County

Homeowner Application

Put your information here!


* - Required field

Basic Information
* Application Date
* First Name
* Last Name
Middle Name
Mailing Address 1
Mailing Address 2
Mailing City
Mailing State
Mailing Zip
Physical Address 1
Physical Address 2
Physical City
Physical State
Physical Zip
Home Phone
Work Phone
Work Phone Extension
Cell Phone
Email Address
County
Ethnicity
Gender
Date of Birth
Source
Marital Status
Employer
Employer Phone
Employer Address Line 1
Employer Address Line 2
Employer City
Employer State
Is there a garage attached to the house?
Have other organizations helped / worked on this property in the past?
Co-Applicant
Name
Relationship to Homeowner
Address
City
State
Zip Code
Co-Applicant Home Phone
Co-Applicant Work Phone
Co-Applicant Work Extension
Co-Applicant Cell Phone
Application
Stock and Bond Value
$
General Areas
Number of Bedrooms
Other Area
Number of Bathrooms
Comments
Number of Living Rooms
Best Time to Call
Number of Other Rooms
Hear About
Municipality
Age
Are you employed?
Recent Repairs/Modifications
Personal Caregiver?
Disabilities
Something about yourself
Annual Income
Signed Consent?
Is a representative filling this application out on behalf of the homeowner?
Disability Comments
If so, please describe relation to homeowner
Household Monthly Income
Year House Built
Monthly Mortgage Payment
Previous Recipient
Monthly utility payments
Program Applying For
Monthly Tax Payments
Own Other Real Estate?
Monthly Insurance Payments
Single/Married?
Head of Household
Were You Ever Convicted Of A Felony?
Head of Household Name
Other Government Assistance
Number of Pets
Types of Pets
Do you own your home or have Tenancy for Life Agreement?
Rate the repairs/modifications in order of importance
Years in Home
Plan to sell home in the next year?
Do you have Homeowners Insurance?
Taxes or other Liens on Home?
Taxes or Liens Description
Current Taxes Paid?
Additional Housing Costs Descriptions
Any family members help with repairs?
If no family members can help with repairs, why not?
In and Out of shower with ease?
Get to bathroom easily?
On and Off toilet with ease?
Smoke/Fire/Monoxide Detectors?
Veteran?
HomeType
Assistance Received
Caseworker
Governmental Assistance
Checking/Savings Account Balance
$
IRA/401 K Balance
$
CD Balance
$
Other Residents
Residents Pay Rent?
If yes, how much rent do they pay?
Residents Living With You
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Name
Relationship
Age
Employed
Disabled
Age Range
Gender
Ethnicity
Veteran
Employer Name
Employer Address Line 1
Employer Address Line 2
Employer City
Employer State
Employer Zip
Employer Phone