1. I have a need:
Please indicate for which program you are applying:
Home Repair Program
If applying for the Home Repair Program, please list
what repairs are needed (use a separate sheet of paper if
Please review our income guidelines. You must fall within the yearly income range for your family size.
1 - $11,750.00 - $23,520.00
2 - $13,400.00 - $26,880.00
3 - $15,100.00 - $30,240.00
4 - $16,750.00 - $33,540.00
5 - $18,100.00 - $36,240.00
6 - $19,450.00 - $38,940.00
2. I have the ability to pay (Please select all that apply)
Have you declared bankruptcy in the past 2 years?
If yes, please give the date of bankruptcy and date of discharge:
Do you pay your rent and other bills on time?
Do you have any outstanding judgments (must pay off prior to application)?
Do you have a stable income that can be verified by pay stubs or letter for the last two years?
Have you been notified that your continued income will be terminated or lessened?
3. I am willing to partner with Habitat
Have you lived and/or worked in Hamblen or Grainger County for at least one year?
Can you provide proof of citizenship or Permanent Residency Status?
Are you willing to partner with Habitat and work at least 300-400 hours of “sweat equity”, attend budget counseling and homeowner workshops, participate in Habitat events, participate in all application evaluation steps, provide all application information in a timely, honest manner and demonstrate a strong commitment to Habitat’s goals?
Date of Birth
Marital Status *
* Legal Documentation May be required.
Are you a Veteran or a current member of the U.S. Arm Forces?
If yes, were you honorably discharged?
If yes, are you disabled?
Please list the co-applicant, if applicable:
Street Address (if different from above)
Date of Birth
List ALL sources of income. You must include source of income, amount BEFORE TAXES, and times paid per month (weekly, biweekly, etc.)
Other acceptable sources of income are: Social Security, Disability, Retirement, and Child Support
Documentation for these will be required and will be verified by Habitat Staff.
Jane Doe, Company Name, $350, Biweekly
Information regarding Credit, Criminal, and Background Verification:
Have you ever been convicted of a felony?
If yes, explain conviction and penalty below. Include
dates of conviction and incarceration.
Has any other member of the household been convicted of a felony?
If yes, explain conviction and penalty below. Include dates of conviction and incarceration.
Please explain other circumstances regarding your or your family’s background, credit, or criminal check that you feel needs explanation:
Release: By my signature, I affirm that all of the information provided in this document is true. I further, by my signature, consent to a thorough Background Check including, but not limited to, Credit History, Employment History, Criminal History, Social Security verification and Permanent Residency Status. I understand that the information provided will be kept confidential. I further agree that false statements on this form will eliminate my eligibility to participate in this program.
By typing your name in the box above you understand that it servers as a legal signature.
Co-Applicant (if applicable)