Dear : Thank you for your interest in Habitat for Humanity Metro Maryland, Inc. s (HFHMM) Home Repair and Weatherization Programs. HFHMM weatherizes homes and provides low- or no-cost home repair services for qualified applicants of limited income. Habitat projects are worked on by volunteers, staff, and partner families with donated money, materials, and supplies. Home repair applicants may be required to pay a small portion of project cost. Repayment amount will be determined by the following sliding scale based upon income level with a minimum payment of $125 (maximum $750) on any project: 30% of Area Median Income or Less Homeowner will pay 1% of project cost 30%-80% of Area Median Income Homeowner will pay 5% of project cost GENERAL GUIDELINES TO QUALIFY FOR HABITAT HOME REPAIR & WEATHERIZATION SERVICES: (s) Must: Have a need for services. Examples include: o Weatherization Services (air sealing, insulation, appliance replacement, HVAC system upgrades) o Critical Home Repairs (accessibility modifications, repair or replacement of critical home components) o Minor Home Repairs (exterior paint, porch repair, gutter/soffit/facsia repair) Be unable to perform the repairs themselves or pay someone to do the repairs. Be willing to partner with HFHMM and contribute the required Sweat Equity hours (up to 10 hours including homeowner education) Be a Montgomery Co. or Prince George s Co. homeowner. Home must be the primary residence of applicant(s) and applicant(s) must have lived in the home for a minimum of one year prior to applying, and plan on living in the home for a minimum of two years after work is completed. Have current homeowners insurance. Have a total household income below the levels listed in this chart: Household Size Maximum Income Annual Allowed (gross) 1 $47,600 2 $54,400 3 $61,200 4 $68,000 5 $73,450 6 $78,900 7 $84,350 8+ $89,800 *there is no minimum income needed to qualify While all applicants residing in Montgomery County will be considered, Prince George s County residents should be aware that HFHMM has selected Riverdale Heights/Riverdale Hills/Crestwood and Kentland-Palmer Park as the focus neighborhoods. Applications from this neighborhood will be given priority for Prince George s County. All applicants will be reviewed by a HFHMM committee. Part of the application process will be a home audit to determine your home s suitability for HFHMM s weatherization and/or home repair services. Please note that homes with unsafe, unsanitary, or illegal living conditions are not eligible for HFHMM s services. Also note that we will need to access key areas in your home to perform these services and, if we cannot safely access these areas due to significant clutter in your home or other reasons, you may not be eligible for services. HFHMM strives to serve as many households as possible. For homeowners who participated in the repair or weatherization program in 2015 or later, HFHMM will not approve applications for additional services within a 7 year period. Along with this application, you must submit: Income verification (paystubs, social security income* etc. at least for the last 2 months OR most recent tax return) Proof of homeowners insurance Utility Release form (attached to application) If approved, you will be required to complete Pre- and Post-Work surveys and attend a homeowner s education session. The application and required documentation will not be returned. Make a copy of the completed application and all documents for your records. Teresa McCoy Project Manager Habitat for Humanity Metro Maryland Inc. Repair@HabitatMM.org Mail or drop off applications at our office Attn: Weatherization & Repair Coordinator Habitat for Humanity Metro Maryland Inc. 9110 Gaither Road Gaithersburg MD 20877-1422 301-990-0014 ext. 15 www.habitatmm.org Fax: 301-990-7536
Home Repair & Weatherization Assistance Application Completed applications with all required documentation must be submitted to be considered. 1. Information Information Co- Information First Name Middle Initial Last Name First Name Middle Initial Last Name q Male q Female q Male q Female of Birth (mm/dd/yyyy): of Birth (mm/dd/yyyy): Home or Cell Phone: Work Phone: E-mail: Home or Cell Phone: Work Phone: E-mail: Present Address: Street City State Zip Number of years at this address: Household Occupants List the names and date of birth for all occupants who live in the home. Do not include the applicant and co-applicant who have already been listed. of Birth Name (first and last) Relationship to (s) (mm/dd/yyyy) 2. Willingness to Partner To be considered for this program, you must be willing to complete Sweat Equity by participating in the walk thru of your home and helping with the work during the work day, should you be physically able. q I / WE ARE WILLING TO COMPLETE THE REQUIRED SWEAT EQUITY HOURS. 1 of 7
3. Services Requested Pictures depicting the problem areas are strongly encouraged Please explain the concerns and priorities you have of your home in regards to the Home Repair and Weatherization Program. Should you qualify, Habitat will complete a comprehensive home visit and will rank any health and safety concerns as a priority. 2 of 7
4. House Information THIS IS A REQUIRED PART OF YOUR APPLICATION. We cannot review applications without this information filled in. Number of Bedrooms: Number of Bathrooms: Total Number of People in Current Housing: Property Information Do you own the property? Are you current on payments OR paid off on your mortgage? q Current q Paid off q Neither Do you have homeowners insurance? Are you current on your property taxes? What type of home do you have? (Single Family, Townhome, or Condo) 3 of 7
5. Financial Information - Monthly Household Income Co- Gross Monthly Wages (Before Taxes): Gross Monthly Wages (Before Taxes): TANF*: Social Security Income: Social Security Disability: SSI*: Alimony*: Child Support*: Section 8 Housing*: Other (Please specify): Total Monthly Income for : TANF*: Social Security Income: Social Security Disability: SSI*: Alimony*: Child Support*: Section 8 Housing*: Other (Please specify): Total Monthly Income for Co-: *You, the applicant are not required to report income derived from these sources. However, if disclosed HFHMM will need to assess; 1. The length of time payments are expected to be received/continue 2. The consistency of the payment history Affiliates may ask about obligations to pay alimony, child support or maintenance as part of the ability to pay determination. Total Monthly Income for any other Household Members (18 years or older; please specify wages, Social Security, etc) : Total Household Monthly Income: REMEMBER you must provide official documentation of all sources of income. 4 of 7
6. Homeowner s Agreement/Waiver I certify that the information I have provided on this application is accurate and that I own the property at the given address. I confirm that all physically able persons in my household available at the scheduled date of services rendered will work alongside the Habitat for Humanity volunteers and staff. I confirm that (except for the conditions listed on this application) my home is a safe place for volunteers to work. I understand that by submitting this application, I am authorizing Habitat for Humanity to evaluate my need for repair and/or weatherization services. I understand that the evaluation will include personal visits and employment verification. I have answered all the questions on this application truthfully. I understand that if I have not answered the questions truthfully, my application may be denied, and that even if I have already been selected to receive weatherization services, I may be disqualified from the program. The original or a copy of this application will be retained by Habitat for Humanity even if the application is not approved. Co- Print Name Print Name Complete if you are NOT the homeowner but are assisting the homeowner in this application Name Daytime Phone Number Is the homeowner aware of this application? 7. Checklist for Required Documents Did you make sure to include the following? A. 2 months of income verification (paystubs, social security income, etc.) Applications CANNOT be reviewed without the following information: Please use this space to provide notes about any information listed in A. B. or C. B. Utility release form C. Proof of homeowner's insurance 5 of 7
8. Optional Information The questions below are optional and do not affect your application status but we appreciate your cooperation. How did you hear about the Weatherization Program? (check all that apply) q TV q Radio q Newspaper q Flyer q Friend q Neighbor q Neighborhood Organization q Other (please specify) Co- What is your occupation? What is your occupation? Race/National Origin (check all that apply): Race/National Origin (check all that apply): q American Indian or Alaskan Native q American Indian or Alaskan Native q Native Hawaiian or other Pacific Islander q Native Hawaiian or other Pacific Islander q Black/African American q Black/African American q Caucasian q Caucasian q Asian q Asian q Other (please explain) q Other (please explain) Ethnicity: Ethnicity: q Hispanic n-hispanic q Hispanic n-hispanic Did you purchase your home through a homeownership assistance program such as HOC, MPDU, etc? If yes, which program?: Is anyone in the household a veteran? Is anyone in the household currently in the military? Is anyone in the household disabled? If yes, indicate type of disability below (check all that apply, please describe if other ): q Uses a Walker, Cane or Crutches q Wheelchair Bound q Blind q Hearing Impaired q Loss of Limb q Mentally Disabled q Other: We Pledge to the letter and spirit of U.S. policy for the achievement of equal housing opportunity throughout the nation. We encourage and support an affirmative advertising and marketing program in which there are no barriers to obtaining housing because of race, color, religion, sex, handicap, familial status or nation origin. 6 of 7
9. Authorizations I, the undersigned, by the execution of the attached consent form grant Habitat for Humanity of Metro Maryland, Inc. permission to do a criminal background check upon the tentative selection of the applicant(s) as a Habitat for Humanity applicant. Co- Print name Print name I, the undersigned, acknowledge that if at any time during the application review process I contact a third party on behalf of Habitat for Humanity Metro Maryland, Inc. my application will qualify for an automatic denial and I will not re-qualify for the program for 7 years. Co- Print name Print name 7 of 7
WEATHERIZATION PROGRAM UTILITY RELEASE FORM I, hereby authorize the release of all information pertaining to my fuel bills, both past and future, to or its designee. Fuel Supplier(s):Name and Address: Electric supplier Account Number: Natural Gas supplier Propane supplier Other supplier I understand that this information will be used only to provide data for the Low-Income Weatherization Program and that the information obtained through this release shall not be made public in such a manner that the dwelling or occupants may be identified. : : Address: