Homeowner Application | Rebuilding Together Oklahoma City

Name

First

Last

Phone

Email

Age

Ethnicity

Hispanic or Latino/a/x
Not Hispanic or Latino/a/x

Race

Homeowner – Tell us about yourself

About Your Home

Home Address

Address Line 1

Address Line 2

City

State

Zip Code

How is your home impacting your health or making you feel less safe?

List of repairs needed

Have you applied for repairs with another organization?

Yes
No

Name of Organization Contacted

Do you plan to remain living in your home?

Yes
No

Is anyone in your family a Mason or Eastern Star Member?

Yes
No

Is anyone in the home a Veteran or a widow(er) of a Veteran?

Yes
No

Emergency Contact

Emergency Contact Name

First

Last

Emergency Contact Phone

Emergency Contact Email

Relationship to Emergency Contact

Questionnaire

Do you own other property?

Yes
No

Other Property Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Information

Type of Home

Single Family
Multi-Family
Condo
Manufactured Housing

Year Built

Move In Year

Unit Insured?

Yes
No

Monthly Mortgage Payment

Current on Mortgage?

Yes
No

Current on Property Taxes?

Yes
No

Household Members – Do other people live in your home?

Yes
No

Household Members

Add each person who lives in your home

Total Monthly Household Income

Proof of Income For Household Members

Examples:

PROOF OF INCOME EXAMPLES:

A copy of all pages of the most recent benefit(s) verification letter(s)
- SSA benefit letter, SSI benefit letter, etc. – For copies of benefit letters, contact the Social Security Administration at 1-800-772-1213
A copy of the most recent 30 day pay stub. The pay stub must include the year-to-date income, company name, and employee name
We do not accept bank statements or tax forms

Copies of the following documents are required to process your application.

ID – Drivers license or birth certificate for all household members/homeowners
Proof of income for all household members/homeowners
DD214 for veterans (If Applicable)
Current year Social Security Benefit Award Letter which may also be known as Cost-of-Living Adjustment.
30 days of most recent payroll statements

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Please Read the Following Information Carefully

Confirmation

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 Oklahoma City and have a basic understanding of the program, its process and the qualifications I must meet to participate. I understand that funds used to repair my home may include funding from the Federal Home Loan Bank Topeka Affordable Housing Program and the Areawide Aging Agency by way of a Grant from the Masonic Charity Foundation of Oklahoma. I give Rebuilding Together Oklahoma City staff or volunteers my permission to inspect my home for purposes of project selection and/or repair. I understand my application may be shared with Funders for inclusion in their services for which I may be eligible.

Photo/media release

I also grant Rebuilding Together Oklahoma City permission to take or have taken photographs and film, including television, of my home. I consent and authorize Rebuilding Together Oklahoma City, its partners, funders, advertising agencies, news media interested in Rebuilding Together Oklahoma City and its work to use and reproduce the photographs and films and 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 its work.

Signature