A Brush With Kindness Application

Your Contact Information

First Name *

Last Name *

Email *

Gender

Date of Birth *

Address Line 1 *

Address Line 2

Phone *

City *

State *

State/Province

Zip *

Postal Code

Country / Region

Social Security Number * The numeric field Social Security Number is required.

Have you served on active duty in US Armed Forces?

Please List Any Family Members and other people living in the home

Name of person 1 The maximum length for the field Name of person 1 is 500 characters.

Relationship of person 1 The maximum length for the field Relationship of person 1 is 500 characters.

Age of person 1 The maximum length for the field Age of person 1 is 500 characters.

Name of person 2 The maximum length for the field Name of person 2 is 500 characters.

Relationship of person 2 The maximum length for the field Relationship of person 2 is 500 characters.

Age of person 2 The maximum length for the field Age of person 2 is 500 characters.

Contact of Person who does not reside in home

Relationship * The field Relationship is required.

Name * The field Name is required.

Phone * The phone field Phone is required.

Is the homeowner or anyone disabled?

Do you work?

if yes full-time / part-time

Do you need a translator

If yes, what language? The maximum length for the field If yes, what language? is 500 characters.

What is the primary concern for repair? The maximum length for the field What is the primary concern for repair? is 5000 characters.

is there a safety hazard of health hazard? The maximum length for the field is there a safety hazard of health hazard? is 5000 characters.

By signing this form, I attest that I have answered all the questions of this application truthfully. I understand if I have not answered the questions truthfully, my application may be denied. If accepted, I agree to an in-home assessment to determine the extent of repair.

I understand that the people who may work on my house are unpaid volunteers: and that Healthy Homes MAKES NO WARRANTIES; EXPRESSED OR IMPLIED REGARDING ANY MATERIALS USED OR WORK DONE BY ANYONE AT MY HOME. I hereby release Newberg Area Habitat for Humanity and any of its affiliated organizations from all actions, claims or demands that I, my assigned, heirs, guardians, and legal representatives now have or may hereafter have for injury or damages resulting from my participation in any Newberg Area Habitat for Humanity activities.

I understand that eligibility is based on need and Income limits as set by HUD guidelines.

I have no present intention to move or offer my home for sale for at least three years.

*Application may be executed and delivered by electronic signature and that the signature appearing on this application are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Printed Name of Applicant The maximum length for the field Printed Name of Applicant is 500 characters.

Date_ The field Date_ must be a date.

Printed Name of Co-Applicant The maximum length for the field Printed Name of Co-Applicant is 500 characters.

Date__ The field Date__ must be a date.

Required information to be included:

1. Copy of the front page of all wage earner(s) most recent tax return who reside in home.

(If not available, then last 2 months of bank statements)

2. Social Security yearly determination if receiving Social Security payments

3. Most recent pay stub(s) if employed

4. Proof of homeownership (copy of mortgage statement or copy of property tax)

5. Copy of Driver’s License or ID card

Information must be either dropped off at office or sent to repairs@newberghabitat.org

Which best describes your race/ethnicity?

Prefer Not to Say The maximum length for the field Prefer Not to Say is 500 characters.

Prefer to describe The maximum length for the field Prefer to describe is 500 characters.

Newberg Area Habitat for Humanity Health Homes program does not discriminate based on age, sex, race, color, ethnic background, national origin, religion, marital status, or sexual orientation