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FOR YOUR CONVENIENCE, YOU MAY DOWNLOAD A .PDF
VERSION OF THE NOMINATION APPLICATION ONLY
SECTION 1
THIS SECTION
BELOW PERTAINS TO BE
PERSON
COMPLETING THIS APPLICATION
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How did you
hear about
TOGETHER
WE PAINT?
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| First Name |
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| Last Name |
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| Address |
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| City |
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State |
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Zip |
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Home
Phone |
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Work
Phone |
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Email |
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Relationship To
Homeowner |
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Are you a member
of a credit union? |
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IF YES, which
credit union(s)
PRESS ctrl
and click for more than one selection |
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SECTION 2
FOR THE PERSON
YOU ARE NOMINATING TO GET ASSISTANCE
Please provide
as much information as possible,
to the best of
your knowledge.
All information
is kept extremely confidential.
IF YOU ARE
NOMINATING YOURSELF,
PLEASE
TYPE "SAME" IN APPROPRIATE BOXES
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HEAD OF
HOUSEHOLD |
FOR THE PERSON
YOU ARE NOMINATING TO RECEIVE ASSISTANCE |
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First Name |
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Last Name |
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Address |
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City |
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County/State |
A
Z |
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Zip |
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Phone |
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Neighborhood/
Community |
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Owner Birthdate: |
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Age |
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Is Homeowner
Disabled? |
Yes
No
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Homeowner Story:
(Share with us
any disabilities, illnesses, or conditions. Please include as much as
possible!) |
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Is Homeowner a
member of a credit union? |
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IF YES, which
credit union(s)
PRESS ctrl
and click for more than one selection |
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Referred By: |
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OTHER
HOUSEHOLD MEMBERS (LIVING IN HOME) |
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Name
Age
Relation |
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Name
Age
Relation |
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Name
Age
Relation |
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Name
Age
Relation |
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How many
children (Under 18) are living in the home?
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How many people
living in the home are able to help paint (if any)? |
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Is Homeowner
currently employed? |
Yes
No
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Where is
Homeowner employed? |
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SECTION 3
QUALIFICATION
FORM
TO BE COMPLETED
BY HOMEOWNER OR AGENT ONLY!
IF YOU ARE NOT
THE HOMEOWNER AND
YOU ARE
NOT AUTHORIZED
TO COMPLETE THIS SECTION,
WE WILL MAIL
THIS FORM TO THE HOMEOWNER.
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QUALIFICATION
FORM
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SECTION 3a
SOURCES OF
MONTHLY INCOME FOR HOMEOWNER
(All information
is kept confidential)
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Social Security |
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SSI |
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Retirement |
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Interest Income |
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Public
Assistance |
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Unemployment |
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Job |
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Other |
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Total Income
Per
Month |
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SECTION 3b
INFORMATION
ON THE HOME IN NEED
(Please provide
as much information as possible)
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Do you own your
home? |
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Is this home
your primary residence? |
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Age of Home?
(Years) |
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How long have
you owned your home? |
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How much do you
estimate your home is valued today? |
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Do you have a
mortgage on your home? |
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If Yes, How much
do you owe on your home? |
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Your house is: |
1 Story
2 Story
Mobile
Home
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Square footage
of home? |
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Constructed of: |
Wood
Frame
Stucco
Brick
Other
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SECTION 3c
ASSISTANCE REQUESTED
(Please provide
as much information as possible)
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EXTERIOR
PAINTING MAKEOVER |
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Would you like
the exterior of your home painted? |
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When was your
home last painted? |
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Is there siding
on your home? |
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Are there any
external repairs needed PRIOR TO painting? |
Yes
No
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IF yes, what
repairs?
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Are you able to
send pictures or video describing your need? |
Yes
No
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REPAIRS &
IMPROVEMENTS |
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Would you like
repairs or improvements completed? |
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IF yes, please
describe in detail, what repairs or improvements would help make
your life easier..
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Are you able to
send pictures or video describing your need? |
Yes
No
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Although we can
not promise any specific repairs/improvements until you have been selected, here
are some examples of what we MAY be able to help with |
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