Home Repair Form

Please fill out the online form, and then submit the following information:

Most recent 4 paystubs, SS/Retirement Statement, etc. from ALL income sources 18 yrs old and older in the household
A copy of your current homeowner’s insurance with premium

The items above can be submitted by:

Fax: 301-698-1697

Email: coralynn.wells@frederickhabitat.org

Mail or Drop Off:
Habitat for Humanity of Frederick County
24 S. Wisner Street, #130
Frederick, MD 21701

Applicant Name

Age

Address

City

State/Province

Zip/Postal

Country

Phone Number

Primary Language Spoken

Will translation be necessary?

Employer

Number of Years Currently Live/Work in Frederick County *

HOUSEHOLD YEARLY Income

Number of Adults in Household

Number of Children in Household (INCLUDE AGES)

How did you hear about Habitat for Humanity of Frederick County's homeownership programs?

Are you a veteran?

Is the homeowner, or anyone living in the home, disabled?

If your application is a more appropriate fit with other, similar programs, may we share it with them? Unless you give us permission to share your information with other organizations, it will be kept confidential. If you check yes, you give Habitat for Humanity your consent to share the information you provided with similar organizations.

Are you still making loan payments on your house?

Which most resembles the size of your house?

What is the square footage of your house?

What year was the home built?

What year did you purchase your house?

Exterior of house

Which most resembles the type of your house?

Have you applied to Habitat for Humanity for home repairs in the past?

Have you had work done at your home by other organizations?

Where did you learn about our Home Repair program?

If selected, I give permission to be photographed on the day(s) of repair

If selected, I give permission to have my name and photograph printed in the local newspaper.

If selected, I am willing to be interviewed by the media about what HHRP is doing with my house.

Briefly describe the type of work you need done on your home. Remember that the items listed below will be considered for repair, but the final decision on what work can be done with our time and financial resources will be made at the discretion of Habitat Home Repair Committee. The work done by HHRP will focus on warmth, safety and independence. Our volunteers are NOT professionals and may not be able to make all repairs.

Personal Statement. If there is anything else you would like to share with us about your home or story, please use the space below.

Homeowner's Agreement. I certify that the information on this application is accurate and that I own the property and primary resident at the address given on this application. I have no intention to move or offer my home for sale or rent for at least 3 years or you will need to pay back 100% of the total cost (including labor). We may put a lien on your house if needed. I confirm that any physically able person residing in my home or visiting for the project that day will work alongside the HHRP (Habitat Home Repair Program) volunteers. I confirm that, except for the condition listed above, my home is a safe place for volunteers. To the extent permitted by law and without affecting the coverage provided by the required homeowner insurance, I waive any rights it may have to recover against Habitat for Humanity of Frederick County, MD and its programs for (1) damages for injury or death to persons or (2) damages to property for claims arising from such damages. This waiver is intended to waive fully, for the benefit of Habitat for Humanity of Frederick County, MD, any rights and/or claims, which might rise to a right of subrogation. I understand that the people who may work on my house are unpaid volunteers: that few, if any of them, are skilled in the building trades; and that HHRP MAKES NO WARRANTIES, EXPRESS OR IMPLIED, REGARDING ANY MATERIALS USED OR WORK DONE BY ANYONE AT MY HOUSE. I hereby release HHRP, Habitat for Humanity of Frederick County and all associated with it from any and all liability whatsoever.

If you are not the homeowner, but are assisting the homeowner in completing the application, please provide your name, contact information and relationship to the homeowner in the box below.