Rebuilding Together Application Screening Form

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The nation's largest organization preserving and revitalizing low-income houses and communities.

Homeowner(s) name(s) and birthdate(s) *

Phone Number(s) *

Address *

Do you own your property? *

Yes

How many people live in this home? *

Have you received assistance from Rebuilding Together or Christmas in April before? *

Yes

If yes, what year was your home worked on?

What is the estimated household income per year for all residents? *

Do you have additional excessive expenses (ie: outstanding loans, medical bills, etc.)? If so, please list below:

Are you a veteran or actively serving in the military? *

Yes

Please list in order of priority the work you need done to your home: *

Please list any additional repairs that are on your wish list:

Please explain any special circumstances that you believe we should know about (medical bills, for example).

**Proof of Ownership, Income, & Residence will be required for the final selection process. Please be prepared to provide the following if you qualify and pass the initial screening (DO NOT SEND NOW)**

1. Proof of Ownership (one only)

a. A copy of current property tax bill

b. OR a copy of the deed to your property

2. Proof of Income (one for all residents in your home)

a. A copy of your (and/or their) last year's federal tax return (1040)

3. Proof of Residence (one only)

a. A copy of a recent telephone bill OR cable TV bill

b. OR a copy of a recent electric or gas bill

I understand that if I qualify I will need to provide the above documents.

Required

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