Name *

First Name

Last Name

Homeowner's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Work Phone

(###)

###

####

Cell/Other Phone

(###)

###

####

Date of Birth *

MM

DD

YYYY

Income Source *

Please Check all that apply

Employment

Unemployment

Veterans Benefits

Social Security

SSI

Pension/Retirement

Child Support

Self-Earned Income

Adoption Subsidy

Foster Care Subsidy

SSDI

Type of Work Needed *

Check all that apply.

Handicap Ramp

windows

Roof Repair

Furnace Repair

electrical repairs

Well

septic

Other

Certification *

By submitting this form, the applicant hereby certifies all information provided in connection with this application is true and correct, and understands that any fraudulent or otherwise intentional misrepresentation may result in criminal and/or civil liability including fines, imprisonment and/or repayment of funds. Please enter your name below. This acts as your electronic signature.

First Name

Last Name

Today's Date *

MM

DD

YYYY

Agreement, Authorization and Release *

Please read the following statements carefully and mark box if you agree. Applicant and all household members age 18 and older: I am authorizing Mecosta County Habitat for Humanity. (MCHFH) to evaluate my actual need for repairs to my home, my ability to repay the amount agreed upon for repairs, and my willingness to partner with Habitat and complete sweat equity requirements. I understand that the evaluation will include personal visits (including an inspection of my home). I understand that providing false information is grounds for denial. I also understand that completion of this application in no way guarantees that I will receive assistance through the MCHFH Critical Home Repair Program. The undersigned hereby releases and forever discharges the officers, directors, agents, employees, volunteers and representatives of the Mecosta County Habitat for Humanity Program as well as the City of Big Rapids, Michigan and the persons or entities providing materials or labor to the rehabilitation, renovation or revitalization work provided to the undersigned residence, from all claims, demands, actions and causes of action relating to any injury or loss which the undersigned may sustain in any way connected with the undersigned's home participating in the Mecosta County Habitat for Humanity program. I also understand that data collected from this application may be used along with other applicant data for statistical analysis. Confidentiality of personal information will be maintained according to MCHFH's Confidentiality Policy. Mecosta County Habitat for Humanity photographs or videos some homes and homeowners. I hereby authorize Mecosta County Habitat for Humanity and organizations with which it partners, to use and/or publish any and all photographs or video of my property and myself and family members.

Yes

Have you read "Your Guide to Fair Housing" *

Yes

No