Rebuilding Together Oklahoma City

Homeowner Application

Thank you for your interest in Rebuilding Together OKC. Our mission is to rebuild lives and neighborhoods…making homes safe, warm and dry. Through the contributions of time, labor, materials, and funding from neighbors who care, we are able to provide repairs at no cost to qualifying homeowners. If you meet the eligibility requirements, please complete the following application and provide copies of mandatory documents.

* - Required field

Section 1
* Application Date
* First Name
* Last Name
* Phone Number
* Date of Birth
* Address
* City
* Physical State
* Zip Code
* Emergency Contact Name
* Emergency Contact Phone
Is a translator needed?
* Is this a mobile home?
* List name(s) as shown on deed
* How many years have you lived in your home?
* Are property taxes current?
* Do you plan to remain living in your home?
* Do you have Homeowners Insurance?
* Do you have a mortgage?
* Is mortgage current?
* Do you own other property?
Section 2
Please tell us about yourself.
How would repairs provided make a difference in your life?
How did you hear about Rebuilding Together?
* Is anyone in the home a veteran?
* Have you or a family member ever been a member of the Masons of the Eastern Stars?
* Have you applied/received services from Rebuilding Together?
* Have you applied/received services from another agency?
Section 3
PLEASE NOTE
  • It is not guaranteed that any or all work will be completed on your home.
  • Specific funder requirements may alter some of the general qualifications.
  • We do NOT provide major plumbing, electrical, foundation repairs or fencing.
Which of the following general repairs do you hope to have completed on your home?
Section 4

Proof of income for all household members is required to qualify for our program. If completing this application online documents can sent via:

  • This application, using our File Uploader
  • Fax: 405.607.0362
  • E-mail: contact@rebuildingtogetherokc.org
  • Mail or in person delivery: 720 West Wilshire #108, Oklahoma City, OK 73116
    *We are happy to make copies of required documents and return originals.
Household Members
Full Name
Date of Birth
Relationship to Homeowner
Gross Monthly Income
Income Source
Would you like to add an another Household Member?
Full Name
Date of Birth
Relationship to Homeowner
Income Source
Would you like to add a third Household Member?
Full Name
Date of Birth
Relationship to Homeowner
Income Source
Proof of Income Examples
If available, please attach the following documents:
A copy of your most recent benefit verification letter
No file is currently uploaded.
Upload File
A copy of your most recent pay stub
No file is currently uploaded.
Upload File
A statement from your employer if paid in cash
No file is currently uploaded.
Upload File
Any verification from a third party about your income statement
No file is currently uploaded.
Upload File
Section 5
Do any household members have a disability or physical impairment?
If yes, check all that apply.
* Have any household members been hospitalized in the past 6 months?’
If Yes, please explain:
* Have any household members fallen in the past 6 months?
* If yes, please explain:
* Are you afraid of falling in your home?
* Do you avoid certain activities due to fear of falling
* If yes, check all that apply.
If 'Other', please explain
PLEASE READ THE FOLLOWING INFORMATION CAREFULLY
* My signature below certifies that the information provided above is true and complete to the best of my knowledge. I have read the information provided by Rebuilding Together OKC and have a basic understanding of the program, its process and the qualifications I must meet to participate. I give Rebuilding Together OKC permission to inspect my home for purposes of project selection and/or repair. I also grant Rebuilding Together OKC permission to take or have taken photographs and film, including television, of my home. I consent and authorize Rebuilding Together OKC, its advertising agencies, news media and any other persons interested in Rebuilding Together OKC and its work to use and reproduce the photographs and films to circulate and publicize the same by all means including, without limiting the generality of the foregoing, newspapers, television media, brochures, pamphlets, instructional materials, books and clinical material for the primary purpose of promoting and aiding its programs and work.
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