Rebuilding Together Oklahoma City

Homeowner Application

Please complete this application in its entirety and to the best of your ability.  Missing and/or incomplete information will slow down the processing of your application considerably.

Please be advised inorder to qualify for this programhousehold income will be required to qualify.


* - Required field
Basic Information
* Application Date
* First Name
* Last Name
Middle Name
* Physical Address 1
Physical Address 2
* Physical City
* Physical Zip
* Physical State
Mailing Address 1
Mailing Address 2
Mailing City
Mailing State
Mailing Zip
Home Phone
Work Phone
Work Phone Extension
Cell Phone
Email Address
County
Ethnicity
Gender
Age Group
* Date of Birth
Other Contact
* Name
* Relationship to Homeowner
Address
City
State
Zip Code
* Non-Homeowner Home Phone
Non-Homeowner Work Phone
Non-Homeowner Work Extension
Non-Homeowner Cell Phone
Application
General Areas
Other Area
Comments
Best Time to Call
* Previous Recipient
* Hear About
* Signed Consent?
* Head of Household
* Disabilities
Income Source
* Household Monthly Income
Annual Income Amount
$
Disability Comments
Monthly Mortgage Payment
Number of Pets
Types of Pets
* Do you own your home or have Tenancy for Life Agreement?
* Years in Home
* Do you have Homeowners Insurance?
If no please explain If yes include Insurance Company and policy number
Taxes or Liens Description
* Current Taxes Paid?
Any family members help with repairs?
If no family members can help with repairs, why not?
In and Out of shower with ease?
Get to bathroom easily?
On and Off toilet with ease?
* Do you have Smoke/Fire/Monoxide Detectors?
* Veteran?
* Are You Raising Grandchildren?
Assistance Received from other agencies?
Caseworker
Checking/Savings Account Balance
$
* Own Other Property?
If Yes, Describe Location and Value
Recent Repairs/Modifications
How will these repairs/modifications be important to you or help you or your caregiver?
Something about yourself
Total number of residents in household
Has Rebuilding Together done work on your house in the last 3 years?
Are you employed?
* Have you or a family member ever been a member of the Masons of the Eastern Stars?
Employer Information
Employer Name
Employer Address
Employer City
Employer State
Employer Zip
Salary/ Hourly Wage
Residents Living With You
This entry will be deleted on submit!
 
Name
Relationship
Age
Employed
Income
Disabled
Gender
Age Group
Ethnicity
Veteran